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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
Outline of Presentation
• What is NADD?• Concept of Dual Diagnosis• Bio-Psychosocial Model of Assessment• Application of Individual Therapy• Group Therapy• Cognitive Behavioral Therapy
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MISSION STATEMENT
To advance mental wellness
for persons with
developmental disabilities through the
promotion of excellence
in mental health care.
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Robert Fletcher, DSW, ACSW, 2004
•NADD Bulletin
Conferences/Trainings
Training & Educational Products
Consultation Services
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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
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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
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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
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Robert Fletcher, DSW, ACSW, 2004
WHAT IS MENTAL ILLNESS?
• Severe disturbance ofthoughtmoodbehaviorand/orsocialand
interpersonal relationships
• Common DisordersMood Disorders
Anxiety Disorders
Personality Disorders
Psychotic Disorders
Adjustment Disorders
Sexual Disorders
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Robert Fletcher, DSW, ACSW, 2004
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)
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Robert Fletcher, DSW, ACSW, 2004
TERMINOLOGY
Intellectual DisabilityMental Retardation
Developmental DisabilityIntellectual ImpairmentLearning Disability (UK)
Dual DiagnosisDual Disability
Co-Occurring MI-IDCo-Existing Disorders
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Robert Fletcher, DSW, ACSW, 2004
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
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Robert Fletcher, DSW, ACSW, 2004
A SUMMARY OF SIMILARITIES AND DIFFERENCES BETWEEN INTELLECTUAL DISABILITY (ID) AND
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
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Robert Fletcher, DSW, ACSW , 2004
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
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Robert Fletcher, DSW, ACSW, 2004
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
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Robert Fletcher, DSW, ACSW, 2004
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
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Robert Fletcher, DSW, ACSW, 2004
FULL RANGE OF PSYCHIATRIC DISORDERSIN
PERSONS WITH ID
III. DISORDERS ASSOCIATED WITH OLDER ADULTSDELIRIUMDEMENTIA
IV. OTHER DISORDERSSUBSTANCE ABUSEFULL RANGE OF PERSONALITY DISORDERS
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Fletcher, 2005
BEST PRACTICEASSESSMENT:
BIO-PSYCHOSOCIAL MODEL
PERSONBIO PSYCHO
SOCIAL
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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
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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
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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
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Sovner, 1986
FOUR ASPECTS OF MR THAT MAY INFLUENCE THE DIAGNOSTIC PROCESS
1. Intellectual Distortion
2. Psychosocial Masking
3. Cognitive Disintegration
4. Baseline Exaggeration
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Sovner, 1986
1. INTELLECTUAL DISTORTION
Emotional symptoms are difficult to
elicit because of deficits in abstract
thinking and in receptive and
expressive language skills.
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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).
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Sovner, 1986
3. COGNITIVE DISINTEGRATION
Decreased ability to tolerate stress,
leading to anxiety-induced
decompensation (sometimes
misinterpreted as psychosis).
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Sovner, 1986
4. BASELINE EXAGGERATION
Increase in severity or frequency of
chronic maladaptive behavior after
onset of psychiatric illness.
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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
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Thompson, Prout & Strohmer, 1994
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
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Thompson, Prout & Strohmer, 1994
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
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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.
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Robert Fletcher, DSW, ACSW, 2004
PSYCHOTHERPAY/ COUNSELING
• RELATIONSHIP BETWEEN A CLIENT AND A THERAPIST
• ENGAGED IN A THERAPEUTIC RELATIONSHIP
• TO ACHIEVE A CHANGE IN EMOTIONS, THROUGHTS OR BEHAVIOR
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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
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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
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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%
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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
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Robert Fletcher, DSW, ACSW, 2004
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Robert Fletcher, DSW, ACSW, 2004
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.
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Robert Fletcher, DSW, ACSW, 2004
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)
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Robert Fletcher, DSW, ACSW, 2004
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
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Robert Fletcher, DSW, ACSW , 2004
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
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Robert Fletcher, DSW, ACSW, 2004
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
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Robert Fletcher, DSW, ACSW, 2004
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
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YAI
TECHNIQUES FORPROMOTING MENTAL WELLNESS
HELP PEOPLE BETTER COPEWITH DAILY PROBLEMS
• LISTEN
• REFLECT
• PROBE
• SUPPORT
• FACILITATE PROBLEM SOLVING
• EVALUATE OUTCOME
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YAI
TECHNIQUES FORPROMOTING
MENTAL WELLNESS
ACTIVE LISTENING
ATTENTIVE
INTERESTED
REFLECT REPEAT A FEW WORDS
REFLECT DEMONSTRATES ACTIVE LISTENING
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YAI
TECHNIQUES FORPROMOTING MENTAL WELLNESS
PROBE
ASK DIRECT QUESTIONS
AVOID INTERROGATION
HOW AND WHAT QUESTIONS ARE USUALLY EASIER TO ANSWER THAN WHY QUESTIONS
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YAI
TECHNIQUES FORPROMOTING MENTAL WELLNESS
SUPPORT
SUPPORTIVE STATEMENTS INDICATE UNDERSTANDING
EXPRESS THAT YOU CARE
ACKNOWLEDGE HAVING BEEN IN A SIMILAR SITUATION
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YAI
TECHNIQUES FORPROMOTING MENTAL WELLNESS
FACILITATE PROBLEM
SOLVING
EXPLORE ALTERNATIVE OPTIONS
SUPPORT ACCEPTABLE SOLUTIONS
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YAI
TECHNIQUES FORPROMOTING MENTAL WELLNESS
EVALUATE OUTCOME
WAS OUTCOME ACCEPTABLE?
WAS IT POSITIVE?
WHAT WAS LEARNED?
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Robert Fletcher, DSW, ACSW - 2004 -
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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
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Robert Fletcher, DSW, ACSW, 2004
STAGES OF PSYCHOTHERAPY WITH PERSON WHO HAVE MENTAL RETARDATION
III. TERMINATION STAGE
- EXPLORE PAST LOSSES
- REVIEWS GAINS MADE DURING THERAPY
- EXPLORE FEELINGS OF TERMINATION
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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
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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
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Robert Fletcher, DSW, ACSW - 2004 -
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Robert Fletcher, DSW, ACSW , 2004
NOQUICK FIX