Dual Diagnosis 101
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Dual Diagnosis 101 Meeting the Behavioral Healthcare Needs of Persons with Intellectual and Developmental Disabilities and Co-occurring psychiatric Diagnoses (IDD/MI). Michael C. Wolff Ph.D., CADC Assistant Clinical Professor, Penn State Department of Psychology

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Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

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., CADC

Assistant Clinical Professor, Penn State Department of Psychology

Assistant Director, Penn State Psychological Clinic


Goals for today

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

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

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

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

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

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

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

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

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 threat

    Video clip (16.45)


Personality disorders

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 C

Anxious/Fearful

The Clusters

Cluster B

Dramatic/Erratic

Cluster A

Odd/Eccentric

Avoidant:

Social inhibition, feelings of

inadequacy, and

hypersensitivity

to negative evaluation

Antisocial:

Disregard for and violation

Of the rights of others

Paranoid:

Distrust and suspicious

of others

Borderline:

Instability of interpersonal

relationships, self image, and

affect, and marked impulsivity

Schizoid:

Detachment from social

relationships and restricted

range of emotional expression

Dependent:

Excessive need to be taken

care of, submissive behavior,

and fears of separation

Histrionic:

Excessive emotionally and

attention seeking

Schizotypal:

Lack of capacity for close

relationships, cognitive

distortions

and eccentric behavior

Obsessive Compulsive:

Preoccupation with order,

perfection, and control

Narcissistic:

Grandiosity, need for admiration

and lack of empathy


Two distinct interactions

Two distinct interactions

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

  • 17:30


What to do

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


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

Etiology

Additional Variables

SES

Vocational

Social outlets

Neighborhood

Loss/Bereavement

Trauma history

Access to health care

Quality of schools

Available treatment

Cultural Influences

Community

Staff

Teachers

Case

Managers

Parents &

Family

Individual

Biology/Health

Hard Wiring

Peers

Thoughts

Feelings

Temperament

Romantic

Meaningful

Adult

Counselors

Therapists

Psychiatric

Why does the individual behave this way?


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

Strategies, Part 1


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

Strategies

  • 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…..


Specific interventions cont common reasons plans don t work

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 interventions catch them doing what you want

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

What factors contribute to the variations in challenging behaviors?

Interventions

Client

Staff


Staff contributions we have found that

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 sec


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

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


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

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

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

Putting it together

Challenging Behavior

Attribution

Emotions

Outcomes

Burn Out

Burn Out


Stress and burnout

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)


Stress and burnout how do we become stressed in workplace

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

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

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

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


Stressful interactions can lead to

Stressful interactions can lead to…

Feelings of inadequacy

or impotence

  • Compassion Fatigue

  • Vicarious Trauma Reactions

  • Wounded Healer

  • Countertransference

Over-inflated

sense of importance

Avoidance

(depression, loss of energy

apathy)

Inability to “let go”

of work/consumers

REGARDLESS WHATYOU CALL IT, IT CAN LEAD TO….

Client/work issues

encroaching on personal time


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

Interventions: Part 2


Evidence based approaches counseling

Evidence based approaches-Counseling


The importance of the working alliance

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

Motivational Interviewing and Stages of Change


What you need to know about motivational interviewing

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

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

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

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 empathy1

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.


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

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

Negative and harmful

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.

  • 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)


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

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.


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

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.

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.


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

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 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


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

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.

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.


Ambivalence is powerful

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!


Michael c wolff ph d cadc assistant clinical professor penn state department of psychology

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.

One final example of ambivalence


Thanks

Thanks !


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