MYTHS AND REALITIES COOCCURRING DISORDERS MENTAL ILLNESS INTELLECTUAL DISABILITY

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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

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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

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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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TERMINOLOGY

• Intellectual Disability
• Mental Retardation
• Developmental Disability
• Intellectual Impairment
• Learning Disability (UK)
• Dual Diagnosis
• Dual Disability
• Co-Occurring MI-ID
• Co-Existing Disorders

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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)

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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.

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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

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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

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MYTHINDIVIDUALS 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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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

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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

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PREVALENCE OF MI 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)

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MYTHMEDICATION 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.

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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

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MYTHPERSONS 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.

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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

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MYTHINDIVIDUALS 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

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CROSS-SYSTEM BARRIERS

• 1. FUNDING ISSUES
• 2. LACK OF COMMUNICATION AND COLLABORATION
• LACK OF QUALIFIED AND TRAINED SERVICE PROVIDES
• 4. PHILOSOPHICAL DIFFERENCES BETWEEN MH AND ID
  SYSTEMS

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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

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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

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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

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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

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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

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CROSS-SYSTEM BARRIERS

• 4. PHILIOSOPHICAL DIFFERENCES BETWEEN MH AND ID
  SYSTEMS
• ? Different language
• ? Different service delivery approaches
• ? Different treatment philosophy

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CROSS-SYSTEM BARRIERS

• PHILIOSOPHICAL DIFFERENCES BETWEEN MH AND ID
  SYSTEMS (continued)
• MH System ID Systems
• Rehabilitation Habilitation
• Recovery Self-Determination
• Medical Model Development Model
• Clients Consumers
• Short Term Approach Long Term Approach

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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

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EFFECTIVE SERVICE SYSTEMS

• THREE INTER-RELATED ASPECTS
• ACCESS
• APPROPRIATNESS
• ACCOUNTABILITY

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EFFECTIVE SERVICE SYSTEMSTHREE INTER-RELATED
ASPECTS

• ACCESS
• ? TIMELINESS
• ? ARRAY OF SERVICES
• ? AVAILABILITY
• ? GEOGRAPHIC PROXIMITY

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EFFECTIVE SERVICE SYSTEMSTHREE INTER-RELATED
ASPECTS

• APPROPRIATENESS
• ? SERVICE MATCHES NEEDS
• ? SERVICE MATCHES RECIPIENTS WISHES
• ? SERVICE ALLOWS FOR SELF- DETERMINATION
  WHENEVER POSSIBLE

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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
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SYSTEMS WORKING TOGETHER OHIOS INTERAGENCY
AGREEMENT

• Mike Schroeder, ODMH
• Glenn McCleese, ODMR/DD
• 2003

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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

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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

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ESSENTIALS FOR SUCCESSBRING TOGETHER THE RIGHT
PEOPLE

• Department leadership
• Representative community people
• Clinical people
• Administrative people
• State resources
• Statewide organizations
• Consumer/family members

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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

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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

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COMPOSITION OF THE ADVISORY COMMITTEE

• Major stakeholders including
• NAMI
• The ARC
• University Affiliated Programs
• Medical Schools
• Boards
• Agencies
• Guardianship Agencies
• OLRS
• Key staff from both systems

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FIRST YEARS

• Developed Best Practices document
• Series of training events
• Stand alone
• Fifth column approach
• Begin attacking systems barriers

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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

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OVERVIEW OF THE NEW ODMR/DD-ODMH INTERAGENCY
AGREEMENT

• Four Sections
• Purpose
• Joint Responsibilities
• ODMH Responsibilities
• ODMR/DD Responsibilities

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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)

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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

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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

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COORDINATING CENTER OF EXCELLENCE

• Training
• Consultation
• Follow-along
• Research
• Technical assistance
• Further development of best practices

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FOR MORE INFORMATION CONTACT

• Dr. Robert J. Fletcher
• NADD (The National Association for the Dually
  Diagnosed)
• 132 Fair Street, Kingston, NY 12401
• Telephone [phone]
• E-mail rfletcher_at_thenadd.org
• Thank you!