Addressing Multiple Conditions

Through Motivational and

Person Centered Approaches

Natalie Marr, Psy.D. LP

Erwin Concepcion, Ph.D. LP

1
 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
 Outline

• Background
• Challenges
• Goals
• Barriers
• Solutions

3
 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
 Degree of Intellectual Impairment
• Mild ID IQ 55 to 70

• Moderate ID IQ 35 to 55

• Severe ID IQ 20 to 35

• Profound ID IQ below 20

5
 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
Co-Occurring Conditions

CD MH

ID

7
 ID and MI Contrasts
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
8
 Myth: People with ID Cannot have a
Verifiable Mental Health Disorder

• Assumption is that maladaptive behaviors are

a function of ID

9
 Myth Buster

• Reality is that the full range of psychiatric

disorders can be represented in persons with
ID

10
 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
 Mental Health Conditions (con’t)
• Associated with older adults
– Delirium
– Dementia
• Others
– Substance Use Disorders
– Sexual and Gender Identity Disorders
– Personality Disorders

12
 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
Type of Diagnosis (n=8501)

ID only Dual dx

n=2,453
29%

n=6,048
71%

14
 Level of [ID] (n=8501)
Dual dx ID only

8.8
profound 18.4

13.6
severe 17.9

27.8
moderate 27.8

49.8
mild 35.8

0 20 40 60 80 100

15
Takes Psychotropic Medications

ID only Dual dx

23%

77%

16
 Type of Psychotropic Taken

ID only Dual dx

30
27
25
25 24
23

20
% YES

16 17

15 13
12
11
9
10 8
6
5 4 4

0
mood only anxiety only behavior only mood + anxiety mood + behavior anxiety + All of them
behavior

17
 Presence of Problem Behavior

MR only Dual dx
100
80
52.8
% yes

60 47.1
40 27.6 26.6 24.4
15.9
20
0
Self-injury Disruptive Uncooperative
(n=1534) behavior behavior
(n=2839) (n=2465)

18
 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
Potential Consequences for the Person
• Homelessness
• Overmedication
• Incarceration
• Hospitalization
• Restrictive services
• “Falling between the
cracks”
• Harmful care

20
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
 Barriers and Challenges in
Collaboration
• Funding barriers to integrated treatment
• Lack of communication
• Training in integrated approaches (both sides)
• Philosophic differences

22
 Philosophical Differences
Intellectual Disabilities System Mental Health System

Habilitation Rehabilitation

Self-Determination Recovery

Development Model Medical Model

Consumers Clients or Patients

Long-Term Approach Short-Term Approach

23
 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
 Integrating Approaches
• Foundations of behavior analysis assert that behavior is lawful and rational to the individual
1

• 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.
2

• 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
3

• 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
4 psychiatric and behavioral intervention

• 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?”
5

• 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
6
25
 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).
 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
 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
 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
 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?
 How do we make our tools work?
• Communication

• Communication

• Communication

• More Communication
 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
Describe
 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?
 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
Describe
 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?
 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?
 Medical Model

Diagnosis Treatment Cure

 Integrated Care Model
Social
Supports
Skill and Family
Physical
Building
Health Care
Support

Person’s
Mental attainment Community
Health Care of the life
s/he wants
 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
 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
 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

• “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