1. Addressing Multiple Conditions Through Motivational and Person Centered Approaches Natalie Marr, Psy.D. LP Erwin Concepcion, Ph.D. LP 1

2. Objectives 1.Identify three benefits to providing integrating care and services for people with co-occurring conditions 2.Identify where participants are in their comfort and own change process for engaging and supporting people with co-occurring disorder in an integrated way 3.Understanding of how current skills can be enhanced to help individuals with co-occurring conditions 4.Identify one next step participants can take to begin addressing multiple conditions facing the individuals they support 2

3. Outline Background Challenges Goals Barriers Solutions 3

4. Intellectual Disability Diagnostic Criteria Intellectual functioning level (IQ) is 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 condition is present from childhood (prior to age 18) 4

5. Degree of Intellectual Impairment Mild IDIQ 55 to 70 Moderate IDIQ 35 to 55 Severe IDIQ 20 to 35 Profound IDIQ below 20 5

6. Mental Illness in People with Intellectual Disabilities Mental Illness: disorders of the brain that disrupt a person’s thinking, feeling, mood, and ability to relate to others. Some of the most common types of mental illnesses seen in people with developmental disabilities include major depression, bipolar disorder, anxiety disorders, personality disorders, schizophrenia and other psychotic disorders, and phobias 6

7. Co-Occurring Conditions 7 CD ID MH

8. Intellectual Disabilities 1.Refers to below average intellectual functioning 2.Incidence= 1-2% of pop 3.Present at birth or prior to age 21 4.Intellectual impairment is permanent 5.Rational behavior at the person’s cognitive & emotional operational level 6.Symptoms of failure to adjust to societal demands are secondary to limited intellectual functioning Mental Illness 1.Not related to IQ 2.Incidence = 16-20% of pop 3.May have onset at any age 4.Often temporary, reversible, and cyclical 5.May vacillate between coping behavior and irrational behavior 6.Symptom presentation is associated with internal and/or external stimuli ID and MI Contrasts 8

9. Myth: People with ID Cannot have a Verifiable Mental Health Disorder Assumption is that maladaptive behaviors are a function of ID 9

10. Myth Buster Reality is that the full range of psychiatric disorders can be represented in persons with ID 10

11. Mental Health Conditions Associated with Childhood – Learning Disorders – Pervasive Developmental Disorders – Attention Deficit – Tic Disorders Associated with Adulthood – Psychotic Disorders – Mood Disorders – Anxiety Disorders 11

12. Mental Health Conditions (con’t) Associated with older adults – Delirium – Dementia Others – Substance Use Disorders – Sexual and Gender Identity Disorders – Personality Disorders 12

13. National Core Indicators Project NCI analysis based upon: – Large random sample – Cross-state data (17 states) – Respondents in community and institutional settings – Data obtained from consumers and proxies on physical and behavioral health, services and supports, community outcomes 13

14. Type of Diagnosis (n=8501) n=6,048 71% n=2,453 29% ID onlyDual dx 14

15. Level of [ID] (n=8501) 15

16. Takes Psychotropic Medications 16

17. Type of Psychotropic Taken 17

18. Presence of Problem Behavior 18

19. Individuals with Dual Diagnosis May sometimes be seen as adults with failed employment histories who reside in homeless shelters and/or within the criminal justice system Have complex needs and are often unable to access the services they need due to insufficient resources Persons with dual diagnosis face difficulties finding appropriate services; often get caught in- between two service systems 19

20. Potential Consequences for the Person Homelessness Overmedication Incarceration Hospitalization Restrictive services “Falling between the cracks” Harmful care 20

21. Commonly Undiagnosed Problems – Seizure disorders (untreated or undertreated) – Chronic pain – Gastro esophageal reflux disease – Autoimmune disorders – Sleep apnea From Dr. Julie Gentile, M.D. 21

22. Barriers and Challenges in Collaboration Funding barriers to integrated treatment Lack of communication Training in integrated approaches (both sides) Philosophic differences 22

23. Philosophical Differences Intellectual Disabilities SystemMental Health System HabilitationRehabilitation Self-DeterminationRecovery Development ModelMedical Model ConsumersClients or Patients Long-Term ApproachShort-Term Approach 23

24. Behavioral Topography Although the topography (what the behavior looks like or sounds like) of behavior may be similar for individuals, the causes and functions of behaviors are very different. 24

25. Integrating Approaches 25 1 Foundations of behavior analysis assert that behavior is lawful and rational to the individual 2 Mental illness often makes these relations difficult to ascertain, as private events are a part of the internal logic and play a critical role in the establishment of patterns. 3 Private events related to the mental illness may crate patterns of behavior reinforced by escape or the opportunity to obtain certain events, people, or activities 4 Understanding that these behaviors serve a function for the individual, no matter how difficult it is to understand, provides a method for linking services for individuals utilizing the best of both psychiatric and behavioral intervention 5 Combining information related to psychiatric symptoms into a behavioral model also eliminates the frequently asked dichotomous question, “is it behavior or is it mental illness?” 6 The most accurate answer to this question is often “both” and without an understanding of how the two interact, a real understanding of the question is impossible

26. Mental Health Overlay on Individuals with Intellectual Deficits Mental Health conditions are often underdiagnosed in this population for a number of reasons (Gustafsson & Sonnander, 2004; Reiss, 1990): – Some disorders may manifest differently (i.e., different symptoms may be evident) across a range of intellectual ability (Powell, 1999) – Diagnostic Overshadowing: Challenging or disruptive behaviors may be attributed to the intellectual disability instead of a potential mental illness (Moss, 2001); cognitive inefficiencies, slowed processing and/or poor executive functioning attributed to intellectual disability – Many diagnostic tools rely on individuals’ ability to express their symptoms verbally (Moss, 2001).

27. Challenging ID/MI Assumptions Individuals with ID can benefit from MH services If a client has a diagnosis that qualifies for mental health services, the presence of any other diagnosis, including intellectual disability, does not exclude that individual from receiving mental health services, and visa versa – Eliminate language like “primary diagnosis” and criteria to receive services that relies on a “which [deficit] came first?” model Coordinated treatment and support should be the standard for individuals with more than one disability who are served in state funded programs

28. Implications/Recommendations for Individuals with ID/MI Assessment and proper diagnosis of psychiatric disorders is key to creating and coordinating a plan for treatment The plan of treatment should incorporate interventions for both MI and ID components – Support providers should note that behavior initially maintained by physical influences can become maintained by social attention or release from demands as well Pay attention to stages of change for the individual and the providers when creating a plan of treatment

29. How does knowing me help them? Human service delivery happens between humans All the same issues that occur in social engagement will be at play in our interactions with those we support

30. Using what we’ve got: Knowing the tools in our toolbox Communication: What are we telling the person? – Verbal – Non-verbal Experience: We must pay attention to our tendency to want to use the same tools with every person we support Relationship: Who are we to this person? How are we using this to his/her advantage?

31. How do we make our tools work? Communication More Communication

32. Activity: Making our tools work Split up into pairs in the room One of you face the back of the room (away from the PowerPoint screen) The other person in the pair look up at the next screen and describe for your partner what you see in three words or less

33. Describe

34. Activity: Evaluate How did that go? Did the person get a good picture of what it was you were describing to them? If they had to, could they have drawn the very object you described? If not, why not? How much more of a description would they have needed?

35. Activity: Making our tools work Now, switch places with your partner and have the person who was describing the first object now face the back of the room (away from the PowerPoint screen) Repeat the previous activity and describe for your partner what you see in three words or less

36. Describe

37. Activity: Evaluate How did that go? Did the person get a good picture of what it was you were describing to them? If they had to, could they have drawn the very object you described? If not, why not? How much more of a description would they have needed?

38. Importance of Integrated Care The previous activity is a simple reminder that verbal communication alone will not give us all the information that we desire when we are trying to develop innovative supports How does Integrated Care help?

39. Medical Model DiagnosisTreatmentCure

40. Integrated Care Model Person’s attainment of the life s/he wants Mental Health Care Skill Building Support Social Supports and Family Physical Health Care Community

41. Integrated Care A Person Centered approach – Balance of “Important to” and “Important for” De-emphasizes any one tool as the most important tool or the tool that will fix everything Integrates information from many angles/sources – Multiple/Competing conditions: Neurocognitive, Mental Health, Substance Use, Medical, etc. Gets the right supports at the right time to the person

42. Next Steps: How can we build Integrated Care settings? Start with the person – What is “Important to” them and “Important for” them? – Team approach – How do we balance the “Important to” and “Important for”? Look at the person and his/her support needs from all angles Seek out multiple resources – Become a recruitor of/advocate for enlisting current resources into the integrated care matrix Never tire of looking for new and more innovative means for supporting the person

43. References Diagnostic Manual—Intellectual Disability: A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability by Robert Fletcher, Earl Loschen, Chrissoula Stavrakaki, and Michael First (Eds.) Kingston, New York: NADD Press, 2007. 552 pp. National Association for the Dually Diagnosed (NADD), http://www.thenadd.org/index.shtml http://www.thenadd.org/index.shtml “Mental Illness and Developmental Disabilities: Some Basics” a presentation by Lara Pallay, LIISW-S Mental Illness/Developmental Disabilities Coordinating Center of Excellence (Ohio) Editorial: Introduction to Special Section on Evidence-Based Practices for Persons With Intellectual and Developmental Disabilities, A. P. Kaiser and L. L. McIntyre, AJIDD, Vol. 115, Number 5: pp. 357–363, September 2010