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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
Individual and Group Psychotherapy for
Persons with MI/ID:
Promoting Mental Wellness
Outline of Presentation
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What is NADD?
Concept of Dual Diagnosis
Bio-Psychosocial Model of Assessment
Application of Individual Therapy
Group Therapy
Cognitive Behavioral Therapy
MISSION STATEMENT
To advance mental wellness
for persons with
developmental disabilities through the
promotion of excellence
in mental health care.
•NADD Bulletin
Conferences/Trainings
Training & Educational Products
Consultation Services
Robert Fletcher, DSW, ACSW, 2004
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
Fletcher, 2005
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
Modified from DSM-IV-TR, 2000
DEGREE OF SEVERITY
REFLECTING DEGREE OF
INTELLECTUAL IMPAIRMENT
Mild ID
IQ 55-70
Moderate ID
IQ 35-55
Severe ID
_____IQ 20-35
Profound ID
IQ below 20
Modified from DSM-IV-TR, 2000
WHAT IS MENTAL ILLNESS?
• Severe disturbance of • Common Disorders
thought
mood
behavior
and/or
social
and
interpersonal
relationships
Mood Disorders
Anxiety Disorders
Personality Disorders
Psychotic Disorders
Adjustment Disorders
Sexual Disorders
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 Diagnosed
2,000,000
(33% of ID – NADD, 2005)
Robert Fletcher, DSW, ACSW, 2004
TERMINOLOGY
Intellectual Disability
Mental Retardation
Developmental Disability
Intellectual Impairment
Learning Disability (UK)
Dual Diagnosis
Dual Disability
Co-Occurring MI-ID
Co-Existing Disorders
Robert Fletcher, DSW, ACSW, 2004
A SUMMARY OF SIMILARITIES AND DIFFERENCES
BETWEEN INTELLECTUAL DISABILITY (ID) AND
MENTAL ILLNESS (MI)
ID:
MI:
refers to sub-average (IQ)
has nothing to do with IQ
ID:
MI:
incidence: 1-2% of general population
incidence: 16-20% of general population
Robert Fletcher, DSW, ACSW, 2004
A SUMMARY OF SIMILARITIES AND DIFFERENCES
BETWEEN INTELLECTUAL DISABILITY (ID) AND
MENTAL ILLNESS (MI)
ID:
MI:
present at birth or occurs before age 21
may have its onset at any age
(usually late adolescent)
ID:
MI:
intellectual impairment is permanent
often temporary and may be reversible and is
often cyclic
Robert Fletcher, DSW, ACSW, 2004
A SUMMARY OF SIMILARITIES AND DIFFERENCES
BETWEEN INTELLECTUAL DISABILITY (ID) AND
MENTAL ILLNESS (MI)
ID:
MI:
ID:
MI:
a person can usually be expected to behave
rationally at his or her cognitive/emotional
operational level
a person may vacillate between normal and
irrational behavior, displaying degrees of each
adjustment difficulties are secondary to ID
adjustment difficulties are secondary to
psychopathology
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
Robert Fletcher, DSW, ACSW, 2004
FULL RANGE OF PSYCHIATRIC DISORDERS
IN
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
Robert Fletcher, DSW, ACSW, 2004
FULL RANGE OF PSYCHIATRIC DISORDERS
IN
PERSONS WITH ID
III. DISORDERS ASSOCIATED WITH OLDER
ADULTS
DELIRIUM
DEMENTIA
IV. OTHER DISORDERS
SUBSTANCE ABUSE
FULL RANGE OF PERSONALITY DISORDERS
Robert Fletcher, DSW, ACSW, 2004
BEST PRACTICE
ASSESSMENT:
BIO-PSYCHOSOCIAL MODEL
BIO
PSYCHO
PERSON
SOCIAL
Fletcher, 2005
BEST PRACTICE
BIO-PSYCHO-SOCIAL MODEL
MULTIPLE SOURCES OF ASSESSMENT
1. Review Reports
2. Interview Family
3. Interview Care Provider
4. Direct Observation
5. Clinical Interview
Fletcher, 2005
BEST PRACTICE
BIO-PSYCHO-SOCIAL MODEL
MULTIPLE SOURCES OF ASSESSMENT
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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
Fletcher, 2005
DIAGNOSTIC OVER SHADOWING
Suggesting that the condition of
mental retardation decreases the
diagnostic significance of a coexisting psychiatric disorder.
Given this proposal, symptoms of
PTSD may be overlooked and be
thought of as a manifestation of
the condition of mental
retardation
Reiss et al, 1982
FOUR ASPECTS OF MR THAT MAY
INFLUENCE THE DIAGNOSTIC PROCESS
1. Intellectual Distortion
2. Psychosocial Masking
3. Cognitive Disintegration
4. Baseline Exaggeration
Sovner, 1986
1. INTELLECTUAL DISTORTION
Emotional symptoms are difficult to
elicit because of deficits in abstract
thinking and in receptive and
expressive language skills.
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).
Sovner, 1986
3. COGNITIVE DISINTEGRATION
Decreased ability to tolerate stress,
leading to anxiety-induced
decompensation (sometimes
misinterpreted as psychosis).
Sovner, 1986
4. BASELINE EXAGGERATION
Increase in severity or frequency of
chronic maladaptive behavior after
onset of psychiatric illness.
Sovner, 1986
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
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
-HOME/FAMILY -WORK
-GROUP HOME
-PEERS
-SOCIAL/LEISURE
Thompson, Prout & Strohmer, 1994
GUIDELINES FOR ASSESSMENT IN
COUNSELING/PSYCHOTHERAPY (CONT.)
VI.
SELECT APPROPRIATE TREATMENT
FACTORS
ANXIETY DISORDER
DEPRESSION
RELAXATION PROCEDURES
COGNITIVE APPROACH
VII. EVALUATE EFFICACY
-OUTCOME MEASURES
-TARGET BEHAVIOR
-LIFE SATISFACTION
-IMPROVED RELATIONSHIPS
Thompson, Prout & Strohmer, 1994
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.
Fletcher, 2000
PSYCHOTHERPAY/ COUNSELING
• RELATIONSHIP BETWEEN A CLIENT AND A
THERAPIST
• ENGAGED IN A THERAPEUTIC
RELATIONSHIP
• TO ACHIEVE A CHANGE IN EMOTIONS,
THROUGHTS OR BEHAVIOR
Robert Fletcher, DSW, ACSW, 2004
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
VOCATIONAL
SEXUAL IDENTITY
IDENTITY CHOICES
AUTHORITY ISSUES
• BOTH REFERRED TO THERAPY BY OTHERS
Strohmer & 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
Strohmer and Prout, 1994
PROBLEMS THAT CLIENTS WITH
BORDERLINE MR AND MR WANT TO
ADDRESS IN THERAPY
Interpersonal Concerns
General Psychological Functioning
Work
Sexuality
Family
Residential Living & Adjustment
Behavior
Financial & Material Resources
Accepting & Coping with Disability
Dealing with Authority Figures
Other
Wittman, Strohmer and Prout 1989
22%
18%
12%
6%
5%
5%
4%
4%
4%
4%
16%
TYPES OF STRESS EXPERIENCED BY PERSONS
WITH
INTELLECTUAL CHALLENGES
I. Ordinary Situations Which Are Not Typically Stressful To The General
Population
A. Social Interactions
B. Meeting New People
C. 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 Life
1. Job
2. Death In Family
3. Home Relocation
B. Adult Expectations
1. Heterosexual Activities: Dating, Sex,
2. Money Management
3. Living Independently
4. Employment
Duetsch, 1989
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.
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)
Robert Fletcher, DSW, ACSW, 2004
PRINCIPLES FOR ACHIEVING A
THERAPEUTIC RELATIONSHIP
• EMPATHETIC
• BE CONSISTENT
UNDERSTANDING
• CONFIDENTIALITY
• RESPECT AND ACCEPTANCE
OF CLIENT
• DRAW THE CLIENT OUT
• EXPRESS GENUINE
• THERAPEUTIC GENUINENESS
• CONCRETENESS
INTEREST IN YOUR CLIENT
• BE AWARE OF YOUR OWN
• ACCEPT THE CLIENT’S LIFE
FEELINGS
CIRCUMSTANCES
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
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
Robert Fletcher, DSW, ACSW, 2004
SERVICE
COMPONENTS
Family Support
Medical and
Dental
Housing
Outpatient
Mental Health
Transportation
Sexual Offender
Service
Inpatient
Mental Health
Person
Hospital Diversion
Substance Abuse
Service
Crisis
Prevention and Intervention
Day Service
Vocational/
Employment
Positive Behavioral
Support
Robert Fletcher, DSW, ACSW, 2004
TECHNIQUES FOR
PROMOTING MENTAL WELLNESS
HELP PEOPLE BETTER COPE
WITH DAILY PROBLEMS
• LISTEN
• REFLECT
• PROBE
• SUPPORT
• FACILITATE PROBLEM SOLVING
• EVALUATE OUTCOME
YAI
TECHNIQUES FOR
PROMOTING
MENTAL WELLNESS
ACTIVE LISTENING
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ATTENTIVE
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INTERESTED
REFLECT
 REPEAT A FEW WORDS
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REFLECT DEMONSTRATES ACTIVE
LISTENING
YAI
TECHNIQUES FOR
PROMOTING MENTAL WELLNESS
PROBE
 ASK DIRECT QUESTIONS
 AVOID INTERROGATION
 HOW AND WHAT QUESTIONS ARE USUALLY
EASIER TO ANSWER THAN WHY QUESTIONS
YAI
TECHNIQUES FOR
PROMOTING MENTAL WELLNESS
SUPPORT
 SUPPORTIVE STATEMENTS INDICATE
UNDERSTANDING
 EXPRESS THAT YOU CARE
 ACKNOWLEDGE HAVING BEEN IN A
SIMILAR SITUATION
YAI
TECHNIQUES FOR
PROMOTING MENTAL WELLNESS
FACILITATE PROBLEM
SOLVING
 EXPLORE ALTERNATIVE OPTIONS
 SUPPORT ACCEPTABLE SOLUTIONS
YAI
TECHNIQUES FOR
PROMOTING MENTAL WELLNESS
EVALUATE OUTCOME
 WAS OUTCOME ACCEPTABLE?
 WAS IT POSITIVE?
 WHAT WAS LEARNED?
YAI
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
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
Robert Fletcher, DSW, ACSW, 2004
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
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
Levitas and Gilson, 1989
Robert Fletcher, DSW, ACSW - 2004 -
NO
QUICK FIX
Robert Fletcher, DSW, ACSW , 2004