Dual Diagnosis 101
Meeting the Behavioral Healthcare Needs
of Persons with Intellectual and
Developmental Disabilities and Cooccurring 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
• 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 noncompliance
• 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 threat
Video 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 A
Odd/Eccentric
Paranoid:
Distrust and suspicious
of others
Schizoid:
Detachment from social
relationships and restricted
range of emotional expression
Schizotypal:
Lack of capacity for close
relationships, cognitive
distortions
and eccentric behavior
Cluster C
Anxious/Fearful
Cluster B
Dramatic/Erratic
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
Narcissistic:
Grandiosity, need for admiration
and lack of empathy
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 control
Two distinct interactions
• http://www.youtube.com/watch?v=A8WvDJGHi4
• 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
Etiology
Community
Staff
Teachers
Parents &
Family
Biology/Health
Hard Wiring
Case
Managers
Individual
Thoughts
Feelings
Temperament
Peers
Romantic
Meaningful
Adult
Counselors
Therapists
Psychiatric
Why does the individual behave this way?
Additional Variables
SES
Vocational
Social outlets
Neighborhood
Loss/Bereavement
Trauma history
Access to health care
Quality of schools
Available treatment
Cultural Influences
Strategies, Part 1
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
• 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!
• 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?
Interventions
Client
Staff
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
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
Challenging
Behavior
Attribution
Burn Out
Emotions
Outcomes
Burn Out
25
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?
• Person Environment
– Interaction between person and work environmentmismatch
• 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
Stressful interactions can lead to…
•
•
•
•
Feelings of inadequacy
or impotence
Compassion Fatigue
Vicarious Trauma Reactions
Wounded Healer
Over-inflated
sense of importance
Countertransference
Inability to “let go”
of work/consumers
REGARDLESS WHAT
YOU CALL IT, IT CAN
LEAD TO….
Avoidance
(depression, loss of energy
apathy)
Client/work issues
encroaching on personal time
Interventions: Part 2
Evidence based approaches-Counseling
Common
Factors
Motivational
Interviewing
PE: Emotion
Focused
Stages of change
Evoking
Working Alliance
• Tasks
• Goals
• Bonds
Arousing
Resolving ambivalence
Empathy
• Attunement
• Perspective taking
• Reflection of feeling
and experiences
• “Maybe I should…Maybe I
shouldn’t… “
• Therapist facilitates
expression of both sides
Be supportive…..
Confrontation will not
lead to development
of “change talk”
Accessing
Empathy
Processing
Integrating
The importance of the Working Alliance
Bordin’s model:
Consists of three
parts
Goals
– Agreement on tasks
– Agreement on goals
– Bond
Bond
Tasks
Motivational Interviewing and Stages of Change
Maintenance
Precontemplation
Action
Contemplation
Preparation
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 can’t cope. You
don’t
understand me.
There is nothing
else I can do.
Nobody is
listening to me.
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 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.
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
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
• 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!
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.
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.
One final example of ambivalence
Thanks !