Dual Diagnosis 101Meeting the Behavioral Healthcare Needs of Persons with Intellectual and Developmental Disabilities and Co-occurring psychiatric Diagnoses

(IDD/MI)

Michael C. Wolff Ph.D., CADCAssistant Clinical Professor, Penn State Department of Psychology Assistant Director, Penn State Psychological Clinic

Goals for today

• Continue to highlight best practice guidelines with respect to working with dual diagnosis populations

• Additional treatment/support strategies – best practice for responding to resistance and difficult behaviors, encouraging services, accomplishing goals, etc.

• Examine staff contributions– working with difficult clients and working to be the best of our ability, and in a less stressed manner

• Putting it all together. Use of video clips and vignettes to facilitate understanding

My background

• Substance Abuse……not that kind• Community mental health (children and

youth/probation) • Psychotherapy– Adults and Children + Families

• Consultation with dual diagnosis populations• Convergence of ideas….

Some of Mike’s Pet Peeves….• Meetings where clients are present and

participants are not speaking directly to the client, but talking as if the client is not present.

• Using terms like “Manipulative” or “Attention Seeking” or “Acting like a baby” or “Scheming” or “Just to make me mad” to describe function of a behavior

• Infantilizing clients; referring to (or talking to) adults as children or kids

• Referring to a challenging behavior as BEHAVIORAL not PSYCHOLOGICAL…it’s really a false dichotomy

No need to be a diagnostician!

• Dimensional far outweighs Categorical– Impulsivity/behavioral control – Agitation/irritability – Processing deficits (sensory)– Social challenges– Mood regulation– Thought disturbance– Behavioral control – Substance induced impairment

In the field – Anxiety • Person experiencing a panic attack• Hypervigilance, obsessions, and

compulsions can look like non-compliance

• Can appear reckless

In the field-Depression

• Can often take the form of extreme irritability • Apathy and lack of cooperation • Hopelessness• Difficulty concentrating, answering questions

and focusing

• Video 2:00

Bi-Polar in the field

• Dealing with a manic individual is very challenging

• Unable to sustain a reciprocal conversation• Sleep disturbances • High energy, inability to regulate mood and

behavior • Engaging in many high risk behaviors including

substance use, sexual promiscuity, and at times illegal activities

Schizophrenia in the field

• Disorganized • Scared and confused• Paranoia can lead to aggression very quickly• Actively psychotic individuals are very difficult

to manage and require a very gentle approach

Autism in the field…..• Non responsive, limited eye contact (can be

mistaken for suspicious behavior)• Irritable and confused• Unable to follow commands (can be mistaken for

non-compliance, non-cooperative)• Highly sensitive to sensory input (noise, touch,

surroundings) hyper/hypo• Can become violent due to inability to

adequately/accurately perceive threatVideo clip (16.45)

Personality Disorders

• Enduring pattern of inner experiences and behavior, which deviates markedly from the norm

• Involves cognition, affectivity, interpersonal functioning, impulse control

• Leads to clinically significant distress • Stable, long duration (patterns tracked back to

adolescence or early adulthood)

The Clusters

Cluster AOdd/Eccentric

Cluster BDramatic/Erratic

Cluster CAnxious/Fearful

Paranoid:Distrust and suspicious

of others

Schizoid: Detachment from social

relationships and restrictedrange of emotional expression

Schizotypal: Lack of capacity for close

relationships, cognitivedistortions

and eccentric behavior

Antisocial: Disregard for and violation

Of the rights of others

Borderline: Instability of interpersonal

relationships, self image, and affect, and marked impulsivity

Histrionic: Excessive emotionally and

attention seeking

Avoidant: Social inhibition, feelings of

inadequacy, and hypersensitivity

to negative evaluation

Dependent: Excessive need to be taken

care of, submissive behavior,and fears of separation

Obsessive Compulsive: Preoccupation with order,

perfection, and controlNarcissistic:

Grandiosity, need for admirationand lack of empathy

Two distinct interactions

• http://www.youtube.com/watch?v=A-8WvDJGHi4

• 17:30

What to do?

• We need to be diligent in our efforts to place ourselves in the shoes of our clients

• Please don’t compare their behavior to how we would handle a situation or struggle, nobody cares, really (we are all just trying to get by)

• Our job is to find a way to be supportive, be empathic, yet maintain personal and professional boundaries……it’s really hard to do

• But first, let’s learn to conceptualize why someone may behave the way they do

Individual

Biology/HealthHard Wiring

ThoughtsFeelings

Temperament

Teachers

Parents & Family

CommunityStaff

Case Managers

Romantic

Meaningful Adult

Why does the individual behave this way?

Additional VariablesSES

VocationalSocial outlets

NeighborhoodLoss/Bereavement

Trauma history Access to health care

Quality of schoolsAvailable treatmentCultural Influences

Etiology

CounselorsTherapistsPsychiatric

PeersPeers

Strategies, Part 1Strategies, Part 1

• Typically, behaviorally oriented strategies have greatest impact on challenging behaviors

• Function of behavior (ABC’s)– Individually tailored interventions

• Incentives prior to punishment• Anticipate problems before they emerge• Meaningful consequences• Consistency• Promote emotional/behavioral control• Appreciate your own contributions…..

Strategies Strategies

Specific Interventions Cont. Common Reasons Plans Don’t Work

• Target behaviors are too broad or not operationalized (must look the same to everyone!)

• Recording procedure too complicated…..data collection fatigue!

• Reinforcement not powerful enough• Too much emphasis on punishment• Not enough emphasis on attention• Failure to clearly specify duties• Tendency to see plan as closed to modification

• Not enough planning/oversight/training

Specific InterventionsCatch them doing what you want!

• Be specific with your praises• Attention is a potent antecedent, it should be

given frequently (positively, that is) • Praise effort over achievement (on task, working

hard, coping, really thinking it through, etc.)• Avoid “good job” or “you were really good today”

….too broad and general (and implies “bad”)• Try “I liked how you _______” or “When you

were ______, that seemed like you really enjoyed yourself, it was nice to see” “You worked really hard earlier when you were…”

What factors contribute to the variations in challenging behaviors?

Client Client

Interventions Interventions

StaffStaff

Staff contributions: We have found that…

• How staff respond to challenging behaviors is determined by multiple influences/causality.– Their understanding or appreciation

regarding the “function” of challenging behaviors– Their views about challenging behaviors in clients,

and their views of self– Their stress level, training, experience, education– Characteristics of employing organization (i.e.

quality of training, supervision, support, etc.)

Video 55 secVideo 55 sec

Staff Contributions: Characteristics and styles of relating known to have positive impact on process

and outcome of interactions

We tend to do better when:– accurate empathy– psychological health • well-being and adjustment

– thoughtful attribution • internal locus of control (what can I do differently?)

– sufficient self-confidence – low reactance• staff-consumer interactions

– (positive) expectancies

Staff Contributions: Characteristics and styles of relating known to have negative impact on process

and outcome of interactions

We tend to do worse when:– highly rigid– hostile (view of others and self)– highly dominant / directive

• high desire for control– external locus of control– lack self-confidence– high stress levels/burnout– negative expectancies of clients – negative attributions/appraisals– reactive

– high tension with consumer

Attributions and appraisal

• Why do they behave this way?• They are manipulative, just to get me upset,

they like doing this, they are hopeless, they are ungrateful…….how are you feeling?

• Task avoidance, preference, escape, disability, hurt/pain (emotionally/physically), sensory, attention, distraction……different response?

• Internal/External• Permanent/Temporary• Controllable/Uncontrollable

Putting it together

25

Challenging Behavior

Challenging Behavior AttributionAttribution EmotionsEmotions OutcomesOutcomes

Burn OutBurn Out Burn OutBurn Out

Stress and Burnout

• At least some responsibility of employer • Leads to increased levels of staff illness,

absenteeism, and turnover/attrition• What can you do about stress and burnout?• Increase awareness, identify sources of stress,

identify outlets for assistance (internal to you, within workplace, outside of workplace)

Video (Van: 6min)Video (Van: 6min)

Stress and BurnoutHow do we become stressed in workplace?

• Person Environment– Interaction between person and work environment-

mismatch• Demand-support-control– Demand high, support/control low

• Cognitive behavioral– Perception of stressors in environment (our

interpretation)• Emotional overload– Exhaustion and personal accomplishment

• Equity theory – Feelings and perception of inequality

Modeling

• What do we model with respect to our own emotional expression?

• How do we cope with strong emotions and stress in general?

Self efficacy

• Sense of agency or confidence• I am able to handle this (optimism)• I feel supported in my role• I have necessary information to respond

effectively • I am able to predict when this may or may not

occur

Emotional reactions

• Attention (don’t do that, you know you are not supposed to do that, no no no….stop)

• Avoidance (whatever, I’m scared of him/her)• Empathy, assistance, nurturance, support• Fear, anger, helplessness, apathy

Burnout and exhaustion Burnout and exhaustion

Stressful interactions can lead to…

• Compassion Fatigue• Vicarious Trauma Reactions• Wounded Healer• Countertransference

REGARDLESS WHATYOU CALL IT, IT CAN

LEAD TO…. Client/work issues encroaching on personal time

Inability to “let go” of work/consumers

Over-inflated sense of importance

Feelings of inadequacy or impotence

Avoidance (depression, loss of energy

apathy)

Interventions: Part 2Interventions: Part 2

Evidence based approaches-Counseling

The importance of the Working Alliance

Bordin’s model:

Consists of three parts

– Agreement on tasks– Agreement on goals– Bond

Motivational Interviewing and Stages of Change

What you need to know about Motivational Interviewing…

• Based on theories related to “Stages of Change” model.

• Does not fit into traditional therapeutic orientation models per se, rather it can augment any approach

• It is a theory for Behavior Change• Four general principles: Express empathy,

develop discrepancy, roll with resistance, support self-efficacy

Express empathy

• Client: Everybody tells me what to do but they don’t understand how I feel

• Counselor: You think people are not understanding you.

• Counselor: Well how do you feel?• Counselor: Maybe they are just trying to help?• Counselor: It sounds frustrating when people

may be trying to help you, but they are missing how you really feel.

Ambivalence: The dilemma of change I WANT TO, I DON’T WANT TO

• Think of a time you wanted to change something about your life

• I want to exercise more, but it is such a time commitment

• My sweet tooth says I want to, but my wisdom tooth says no

• I want to meet new people, but I don’t feel I’m a worthwhile person to meet

• I don’t want to party as much as I have been lately

Let’s take a closer look • Client: “I’ve tried so many times to change,

and failed.” • Counselor: “Why have you failed?” • Counselor: “You should keep trying” • Counselor: “Maybe you need a different

approach”

• Counselor: “You’re very persistent, even in the face of discouragement. This change must be really important to you”

Express empathy

• Client: Everybody tells me what to do but they don’t understand how I feel

• Counselor: You think people are not understanding you.

• Counselor: Well how do you feel?• Counselor: Maybe they are just trying to help?

• Counselor: It sounds frustrating when people may be trying to help you, but they are missing how you really feel.

Some counselor reactions may be negative and harmful, yet at times can be well intentioned but unhelpful

Negative and harmful • Blaming the client • Accusing client of being

manipulative • Avoiding, belittling, or

antagonizing the client• Fearful of client • Angry that client is not

changing (and expressing it directly with client inappropriately)

Well intentioned but unhelpful• Giving advice • Disagreeing with client• Offering alternative

suggestions • Wanting so much for the

client to see the errors of their way, or the RIGHT way.

I don’t want to be this way. It

used to be better. I know I can do this but it’s too damn hard. Some

things help, but not enough.

I can’t cope. You don’t

understand me. There is nothing

else I can do. Nobody is

listening to me.

It does feel good to talk to

someone. There was one therapist who helped me. If I had the time, I would go back

to group as well.

I don’t need to be in

counseling. It won’t help me anyway. I tried

it before and was always let down. I can’t work if I am in counseling. I

have too many other things going on.

I do like to spend time with my

friends, I do like making a little

money, I just want to be able to make decisions for myself

I do like to spend time with my

friends, I do like making a little

money, I just want to be able to make decisions for myself

I don’t like my day

programming, I don’t like working

anymore, you can’t make me do

things I don’t want to do

I don’t like my day

programming, I don’t like working

anymore, you can’t make me do

things I don’t want to do

I know it is not healthy, but I

keep going back. Many of my

needs are not being met, but he needs me. I have

thought about leaving, I just

don’t know where I would go.

He is the only one who

understands me. I can’t live

without him. We must be

together. He is mean, but

nobody else understands him. I can’t leave him.

Ambivalence is powerful

• Remember if we focus on Naming and Empathizing regarding a consumer’s ambivalence, rather than Changing behavior (at least to start), we are more likely to:

• Decrease challenging behaviors, increase our sense of self efficacy, decrease our stress and burnout, and improve our relationships with the people we serve!

I guess there was some good

information. At least Dr. McGonigle

was helpful. I really could try and implement some of this information in

my work.

I guess there was some good

information. At least Dr. McGonigle

was helpful. I really could try and implement some of this information in

my work.

Ok, that Mike Wolff guy was

pretty boring. His 3 hour talk was about 2.5 hours too long. I could

have been getting paperwork done during this time.

Ok, that Mike Wolff guy was

pretty boring. His 3 hour talk was about 2.5 hours too long. I could

have been getting paperwork done during this time.

One final example of ambivalence One final example of ambivalence

Thanks !