Introduction to Dual Diagnosis - Dual Diagnosis A Credo for

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					                                              Strength based introductions
          Dual Diagnosis                      A few roels of perosn and the strengths
                                              they have that they bring to those roles

                Martha Marr

                                          1                                              2

       A Credo for support                           Acknowledgements          Material developed – Innovations grant –
 DfZFxXw                                      CMHA Ottawa Branch - MCSS

                                              Dorothy M. GRIFFITHS, Chrissoula
                                              STAVRAKAKI, Jane SUMMERS
                                                         “Dual Diagnosis “

                                              Martha’s Experience
                                          3                                              4

  Today is part of a larger picture of
   training . Goal is to enable staff ,
                                                        Dual Diagnosis
     increase their competence and
  confidence in their roel supporting           Mental Illness
 people with complex needs. Today is            Developmental Disability
    intro to some of the Diagnosis ,
                                                Dual Diagnosis
interactions from having 2 diagnosis .
                                                Special issues
Followed up by the online course then
                                                The Biopsychosocial Approach to working
   followed up by a part 2 where we
                                                with dual diagnosis
 spend time doing a Bio Psycho social
  interventions for some situations .
                                          5                                              6
                                                  How many psychiatrists does it
 How many therapists does it
                                                   take to change a light bulb?
 take to change a light bulb?
None. The light bulb will change itself           "How long have you been having this
when it's ready.                                  fantasy?"
                                                  "Why does the light bulb necessarily have
Just one, but the light bulb really has to        to change?"
want to change.                                   One, but he must consult the DSM-IV.
Just one, but it takes nine visits.

                                              7                                               8

How many psychoanalysts does
 it take to change a light bulb?

"How many do you think it

                                              9                                           10

                                                    What is a Dual Diagnosis?

                                                  A Dual Diagnosis indicates the
                                                  presence of a psychiatric illness as
                                                  well as the presence of a
                                                  developmental disability, occurring
                                                  simultaneously in an individual – that
                                                  results in ongoing mental health and
                                                  cognitive challenges.

                                             11                                           12
     Interministerial guidelines published
                January 2009                                                   Developmental Disability
Two definitions of developmental disability
                                                                           “A particular state of functioning that
1.   MCSS (Developmental Services Act): a condition of mental              begins in childhood and is characterized
     impairment, present or occurring during a person’s formative          by limitations in both intelligence and
     years, that is associated with limitations in adaptive behaviour.
                                                                           adaptive skills”
2.   MOHLTC (DSM-IV-TR): characterized by significantly sub-                              AAMR
     average intellectual functioning (an I.Q. of 70 or below) with
     onset before age 18 years and concurrent deficits or impairments
     in adaptive functioning.

                                                                    13                                                      14

                                                                               Developmental Disability
                    ADAPTIVE SKILLS
      Communication                     self direction                     Impaired ability to learn causing difficulty
      Self-care                         health and safety                  coping
      Home living skills                functional academics               Usually present from birth
      social skills                     Leisure                            Not the same as mental illness
      community use                     Work
                                                                           Milestones - Developmental delay
     • Emphasize the person strengths,
     interests, gifts and talents adapt the
     environment so that they are used .
                                                                    15                                                      16

          Developmental Disability                                             Developmental Disability
     What are some of the challenges you might                           Limitations or impairments in two or more of the
     expect to encounter if you are working with                           following adaptive skills:
     someone who has a developmental disability ?                          Communication
        Communication problems                                             Home living
        Self injury
                                                                           Community use
        Issues re: self care, mobility, language
        Hospitalization                                                    Health and safety
        Medication                                                         Leisure
        Isolation                                                          Self care

                                                                    17                                                      18
   Developmental Disability                                Developmental Disability

Social skills                                           I.Q. testing is not used to diagnose, rather
Self direction                                          to differentiate between levels of
Functional academics                                    disability:
                                                          Mild = 50–55 to @ 70
                                                          Moderate = 35-40 to 50-55
                                                          Severe = 20-25 to 35-45
                                                          Profound = below 20-25

                                                   19                                              20

   Developmental Disability                                Developmental Disability
Syndromes/disorders associated with
developmental disability:                               Unique issues:
  Developmental delay                                     Vulnerabilities
  Down Syndrome                                             Biological
  Chromosomal abnormalities                                 Psychological
  Phenylketonuria                                           Social
  Fragile X Syndrome
  Cerebral Palsy
  Prader-Willi Syndrome
                                                   21                                              22

   Developmental Disability                                   Developmental delay
Biological Vulnerabilities:                             Childhood milestones met late or not at all
  More likely to have physical illnesses such as        Lift head .crawl/walk talk/ etc
  ear, nose, throat, congenital heart disease,
  gastrointestinal, seizure disorders, etc.             Difference between infant or toddlers
  Less likely to be able to express their               current level of functioning and the
  experiences of pain and discomfort due to             expected Milestones for chronological age
  communication difficulties
                                                        to the month
  Higher risk of medical misdiagnosis
  Greater sensitivity to certain medications

                                                   23                                              24
          Down Syndrome                                         Cerebral Palsy
Genetic disorder
10% of people with developmental                     Disorder of movement and posture
disability have DS                                   resulting form a non-progressive lesion in
Increased vulnerability to eye heart lung            the brain acquired during childhood
skin and gastrointestinal disorders                  development
Usually short stature, round face, almond            Cerebral = Brain and Palsy = Paralysis
eyes, broad hands and feet                           Spastic rigid limbs
Low muscle tone and hyper flexibility                Speech disorders poor coordination
joints                                               Difficulty with balance and unusual gait
                                                25                                                  26

          Autism spectrum                                    Fragile X syndrome
Disorder of Neurological condition                   Genetic disorder most common inherited cause
                                                     of developmental disability
Unknown cause                                        Affects 2X more makes than females
Difficulty with language, social                     Females with Fragile X can have normal range of
relationships, sensory stimulation, and              intelligence males are more severely impacted
cognitive processing                                 Often a missed diagnosis
4 times more frequent in males                       Characteristics = stereo topic movements
                                                     elongated face, large ears.
Manifest prior to the age of 3                       Limned eye contact
Degree’s vary greatly                                Difficulty with social relationships

                                                27                                                  28

       Prader –willi syndrome
                                                          Phenylketonuria (PKU)
Genetic disorder present at birth
Excessive hunger and unusually large food            Genetic disorder whereby an infant lacks
                                                     the required enzyme to metabolize PKU
Mild to severe intellectual disability X profound
                                                     If undetected leads to brain damage and
Small stature, low muscle tone, almond eyes
small hands and feet , perpetual pre teen            development disability
Poor emotional and social skills                     Heel - prick test at birth .. Can be treated
Test high for reading, writing , number skills and   with diet
abstract thinking than their intellectual
                                                29                                                  30
    Developmental Disability                                    Developmental Disability
Psychological Vulnerabilities:                              Social Vulnerabilities:
  We all develop our personalities the same way: social       Social isolation
  interaction; play; how we relate and respond to
  others and how they relate and respond to us.               Artificial friendships
  People with DD are often excluded from “normal”             More prone to victimization and exploitation
  experiences                                                 More easily intimidated or coerced
  Stigma/negative social reactions
                                                              Lack of opportunity to learn to value
  May not get opportunity to develop independent skills
                                                              themselves and achieve social success
  More vulnerable to mood and anxiety disorders ?

                                                       31                                                          32

      Common mental illness with                             … Common mental illness with
        Types of Disorders                                       Types of Disorders
Communication Disorders:                                    Attention Deficit and Disruptive Disorders:
  Means: anxiety, depressive, adjustment disorder             Means: inattention, hyperactivity, impulsivity
  What Helps: alternate ways of communicating                 Increase: likelihood of disruptive behaviour, anxiety,
                                                              depression, sexual disorder
Pervasive Developmental Disorders:                            Hard to find: Dev. Dis. all ready have short attention
  Means: severe-pervasive impairment social                   spam-excessive motor activity – impulsivity
  interaction/communications skills, stereotype             Feeding Disorders:
                                                              Means : eating non-nutrive substances
  40% person with developmental disability
  What Helps: helping support individual and caregiver        Pica very common, but difficult to modify
  in primary disability
                                                       33                                                          34

 … Common mental illness with                                … Common mental illness with
     Types of Disorders                                          Types of Disorders
Eating Disorders:                                           Elimination Disorders:
  Means: Anorexia, bulimia, binge eating                      Enuresis:
  RARELY DIAGNOSE because INTENT                                 no control of urine, day and night in bed or
  Compulsive over eating (Common)                                clothing
Tic Disorders:                                                   repeated passage of faeces into inappropriate
  Means: Rapid, recurrent, non rhythmic, stereotypes             places
  motor movement or vocalization                              Greater disability, greater the frequency
  Does not include autism                                     Cause: neurological, anger, fear, agitation,
                                                              lack of opportunity of appropriate training          36
 … Common mental illness with                                            … Common mental illness with
     Types of Disorders                                                      Types of Disorders
Mood Disorders:                                                         Sleep Disorders:
                                                                          Very common
  Common in mildly and moderate                                           Neurological deficit

Anxiety Disorder:                                                       Adjustment disorders:
  Observe behaviour for lower functioning                                 Psychological or physical trigger, last self-limiting time
                                                                          Frequent with mild and moderate

Eating Disorders:                                                       Delirium
  Common overeating                                                       Means: change of cognition due to medical
  Prader-Willi = obsessive-compulsive eating                              some symptoms similar to schizophrenia

                                                                   37                                                                  38

 … Common mental illness with
                                                                                         Mental Illness
     Types of Disorders
                                                                        Everyone experiences feelings of isolation,
Demantias                                                               loneliness and emotional distress at times. These
  Means: loss of multiple cognitive deficits                            feelings are normal and are usually short-term
  Symptoms: memory impairment (3 kinds):                                and related to life events – we cope.
     Apraxia (impaired motor activity)                                  For some people these feelings are so intense
     Aphasia (deterioration language)
                                                                        that their ability to cope is overwhelmed and
     Agnosia (failure to identify, recognize objects), disturbance in
     executive functioning                                              they cannot function in their social roles.
   Most be based on evident deterioration of pre-                       20 % of Canadians will experience a mental
  existing level of cognition                                           illness during their lifetime
                                                                   39                                                                  40

                Mental Illness                                                           Mental Illness
                                                                        What are some of the challenges you might expect to
Mental illness is caused by a complex                                   encounter if you are working with someone who has a
interplay between biological, genetic,                                  mental illness?
                                                                          Symptoms of illness
environmental and personality factors.                                    Medication and compliance issues ?
                                                                          Homelessness/ housing instability ?
You can have more than one mental                                         Addiction ?
illness e.g. depression and anxiety                                       Family problems ?
                                                                          Problems with criminal justice system ?
More episodes of MI the greater the                                       Unemployment ?
                                                                          Lack of education ?
degree of disability                                                      Poverty ?
                                                                          Hospitalization ?

                                                                   41                                                                  42
                 Mental Illness                                               AXIS II

The four major mental illnesses are:                       Disorders diagnosed in infancy, childhood or
                                                           Developmental Disability:
      Affective or mood disorder                             Communication Disorders
      Anxiety Disorder                                       Pervasive Developmental Disorders
      Personality Disorders                                  Attention Deficit and Disruptive Behaviour Disorders
                                                             Feeding and Eating Disorders of Infancy or Early
                                                             Tic Disorder
                                                             Elimination Disorder

                                                      43                                                            44

      Degrees of Develop. Disability &
      potential risk of mental illness                                  Schizophrenia
  1. Mild: (85% of Dev. Dis. Pop.)                         Schizophrenias are one of the most
 “educable”, to a 6th grade level                          severe, chronic and disabling brain
  social and communication skills                          disorders
  •    traumatic and adverse experience (rejection)        Disturbances of thought (delusions and/or
 cause: prior or after birth, infections, medical          hallucinations), mood, sense of self and
 condition, traumas
                                                           relationship to external world, language
 anxiety and mood disorders because academic               and communication, regressive and
 and social expectation greater then cognitive
                                                           bizarre behavior.
                                                      45                                                            46

                 Schizophrenia                                          Schizophrenia

 Types include:                                            Onset: late teens to mid-30’s
      Paranoid                                             Preadolescent onset is rare
      Catatonic                                            Men and women are equally affected
                                                           Males usually have earlier onset
                                                           If onset is after the age of 45, person is
  Affects 1% of population
                                                           usually female and likely to have a larger
  Much higher prevalence in the Developmental
                                                           mood component

                                                      47                                                            48
             Schizophrenia                                          Schizophrenia
Diagnosis                                               Symptoms:
  No lab test for schizophrenia                           Delusions and or hallucinations
  Clinical observation
                                                          Lack of motivation
  Symptoms must be present for at least 1 month
  Persistent for 6 months
                                                          Social withdrawal
  Must be causing marked social, educational, or          Thought disorders
  occupational dysfunction                                Bizarre behavior
  Family history                                          Blunted affect

                                                   49                                              50

Dual diagnosis and Schizophrenia                        Dual diagnosis and Schizophrenia
    (What it might look like)                               (What it might look like)
Diminished self care                                    Appearance of new unusual mannerisms
Aggressive behaviour
Uncontrolled yelling                                    Quick glances or movements
Difficulty dealing with others                          Complaints of strange smells
Labile affect ( laugh or cry at inappropriate           Insecure statements “ you are going to
Behaviour indicating new fears or suspicion             put me in jail/hospital /institution”
others                                                  Denying or admitting guilt related to
Talking-to non existent objects or people
                                                        delusional thoughts” I burned the house”
Regression in language skills
                                                   51                                              52

 Affective or Mood Disorders                             Affective or Mood Disorders

Major Depression                                        Major Depression
Bipolar Disorder                                        8% of adults
Dysthymia                                               Higher rates for women (ratio 2:1)
Onset is adolescence to early adulthood                 Symptom differences based on gender
                                                          Males = irritable, angry, discouraged
Late diagnosis is common
                                                          Females = feeling worthless, helpless,
Ratio equal between males and females                     persistent sad mood

                                                   53                                              54
                                                                  Dual diagnosis and Depression
                Major Depression
                                                                    (What it might look like)
Symptoms:                                                        Increased agitation
     Mild, moderate or severe
     Difficulty coping                                           Destruction of property
     Feelings of uselessness, hopelessness                       Restlessness
     Anger or irritation
                                                                 Increased SIB
  Memory problems                                                Spending more time alone/ refusing phone calls
  Difficulty concentrating                                       Lack of interest in Rec/ leisure
  Extreme restlessness or fatigue
  Sleep problems (too little or too much)
                                                                 Spontaneous crying
  Suicidal or homicidal thoughts                                 Refusal of meals or agitation around meal times
  Hallucinations or delusions                                    Fear
                                                                 Changes in sleep/ weight

                                                          55                                                        56

                 Bipolar Disorder                                            Bipolar Disorder
Affects 1% of the population                                     Excessive energy
   Sustained periods of depression alternating with periods
   of mania with normal mood in between.                         Decreased need for sleep
   Mania: feeling high, euphoric or agitated                     Increased sex drive
                                                                 Poor judgment (risky behavior)
Symptoms of mania:
  - elevated or expansive mood                                   Hallucinations or delusions
  - as mood gets higher:                                         racing thoughts/ flight of ideas/rapid speech
             - extreme irritability
             - rapid emotional changes                           over-reaction
                                                               (1 % of the population Mortality rate is 2-3 times
                                                          57                                                        58

                                                                     Dual diagnosis and Bi-polar
                                                                      (What it might look like)
  Chronically depressed mood
  No long symptom-free periods                                   SIB associated with irritability
  Depression lasts most of the day                               Attention deficits
  More depressed days than not in past two                       Inflated self esteem and grandiosity
  years                                                          Repetitive speech/disorganized thoughts
                                                                 Easily provoked /Teasing others
                                                                 Suicide attempts
                                                                 Demands to have needs met
                                                                 Decreased need for sleep
                                                          59                                                        60
           Anxiety Disorder                                          Anxiety Disorder

Persistent, extreme or pathological anxiety               Included are:
   A debilitating level of anxiety                          Panic Disorder (more common in women than
   Feelings of fear in anticipation of events               men)
   Self-judged inability to cope                            Generalized Anxiety Disorder
   Rapid heart rate                                         Obsessive Compulsive Disorder
   Elevated blood pressure                                  Phobias
   Disturbances in mood or emotions                         Post-Traumatic Stress Disorder

                                                     61                                                          62

     Dual diagnosis and Anxiety
                                                                 Personality Disorders
      (What it might look like)
 Rocking body , rubbing hands                             A long-standing way of relating to self and
 Usually tied to post traumatic stress and history        environment that becomes so fixed and
 of abuse                                                 rigid it causes personal distress and
 Aggression                                               impairs functioning.
 SIB                                                      As a result of their maladaptive way of
 Destruction of property                                  relating to the world, individuals with a
 Persistent talk on upcoming activities                   personality disorder often struggle in
 Hyperventilate/panic attacks                             social, occupational and educational roles.
                                                     63                                                          64

        Personality Disorders                                    Personality Disorders

 Personality develops in early infancy and                Characteristics:
 childhood                                                  Do not do well in social or occupational roles
                                                            Often demanding, intolerant, irrational, manipulative,
 Personality traits become personality                      inconsistent, opposing, threatening.
 disorders when they become rigid and                       Sometimes violent or self-destructive
 inflexible, impair functioning and cause                   Passive aggressive behavior
 distress.                                                  Hypochondria
                                                            Defective sense of reality

                                                     65                                                          66
                                                       Dual diagnosis and personality
         Personality Disorder                                    disorders
                                                         (What it might look like)
Types:                                                Volatile nature of interpersonal relationships
  Paranoid personality disorder                       Impulsive goal directed which could include
  Schizoid personality disorder                       drinking binges or stealing
  Histrionic personality disorder                     Difficulty controlling anger/ verbal tirades
  Narcissistic personality disorder                   Suicidal threats vulnerable to suicide
  Anti-social personality disorder                    Constant unreasonable demands placed on
  Borderline personality disorder                     people in their network anger if not met
  Dependent personality disorder                      Limited insight into behaviour/ illness

                                                 67                                                    68

    Impact of Mental Illness                                      Dual Diagnosis

Education                                             What are some of the challenging
Occupation or career opportunities                    behaviors you may encounter in working
Personal relationships                                with someone with a dual diagnosis?
Stigma and discrimination

                                                 69                                                    70

            Dual Diagnosis                                        Dual Diagnosis
Approximately 80,000 individuals in Ontario have      Most common MI in persons with
a developmental disability
Approximately 24,000 or 30 % have a mental            developmental disability:
health issue. Some researchers state the prevalence     Mood Disorders
may be as high as 50-60%
                                                        Anxiety Disorders
Psychiatric disorders are one of the main causes of
a secondary disability in the developmentally              OCD
disabled                                                PTSD
Often people with a developmental disability are        Schizophrenia
not assessed for mental health issues or are
                                                 71                                                    72
           Dual Diagnosis                                      Dual Diagnosis
Signs and symptoms/ what to look for:               Symptoms of undiagnosed mental illness
Eating                                              can be perceived as many things e.g.
Sleeping                                            aggression, self-harm behavior etc. and
Hyper/ under vigilance                              can result in challenging behavior.
Changes in patterns of behavior (isolation,         Challenging behavior can lead to:
excitability, fixation)                               Hospitalization
High index of suspicion given the prevalence          Housing instability
Know your client
                                               73                                             74

Lingo /terminology/acronyms
Smi                                                               I define me
Severe and persistent
Axis 1 2 3 4                              
Dd                                                  JTXTYY
concurrent disorders /cd harm reduction
Life domains
Adls psr pcs pcp srv oisd                      75                                             76

                                                              Innovations DVD

Day 2

                                               77                                             78
The Biopsychosocial Approach                                  The Biopsychosocial Approach
The evidence-based best practice approach to                  The application of the BPS model to dual diagnosis
working with individuals who have a dual                      is innovative. In this approach, challenging
diagnosis                                                     behaviour is seen as a symptom of a larger issue
                                                              and becomes the focus of multidisciplinary
A movement away from managing behaviors                       assessments into the origin of the behaviour.
towards understanding behaviours.                             The term ‘challenging behaviour’ can refer to a
The BPS approach looks beyond the obvious and                 variety of behaviours, however, behaviours that
explores the origins of behaviour from a holistic             are targeted through intervention strategies are
viewpoint.                                                    usually aggressive in nature.

                                                         79                                                   80

The Biopsychosocial Approach                                  The Biopsychosocial Approach
Challenging behaviour is the external symptom of              In the BPS model the “focus person” is
an often complex interplay between any number                 supported by a multidisciplinary team. This
of biological, psychological and social factors.              team is made up of professionals from a
                                                              variety of disciplines such as neurology,
These factors are:                                            family medicine, psychiatry, occupational
BIOMEDICAL                                                    therapy, recreation therapy, social work as
PSYCHOLOGICAL                                                 well as non- professionals such as the
SOCIAL                                                        individual, family and friends.

                                                         81                                                   82

The Biopsychosocial Approach                                  The Bio psycho social approach
Family an friends : support network, collateral               We must understand the function of behaviour
Social worker: advocacy, intervention, coordination of        Understand the context
services , direct services, planning
Nurse : assessment , treatment ,education, medical
investigations                                                    Personal vulnerabilities
Neurologist: Brain activity patterns
Psychiatrist: assessment ,diagnosis, treatment
                                                                  reinforcing factors
Occupational Therapist: skills assessment , and               Once we understand the context we can
development                                                   hypothesis the function and teach replacement
Recreation therapist leisure, and recreation
                                                              behaviours that are more functional
Psychologist : Therapy

                                                         83                                                   84
                      Gussepe                                                     Gusseppe
43 year old male                                                  Acute hospitalization
Grew up in institution – 30 years                                 No thorough assessment
No major behavioral issues reported –                             Relevant tests not completed
communication frustrations tantrums .                             Began to stabilize somewhat ( eat/sleep/med
Blind                                                             compliance )
Small stature C-spine scoliosis                                   Some days still with SIB’s and screaming
Moved to community to moderate support group                      Severe MR level
home – did well of two years                                      Psych unit transferred to general bed unable to
Then withdrawal, weight loss , tantrums, yelling                  make a psych diagnosis
screaming, sib’s, crawl up on the window sill in                  Similar periods of stabilization and agitation
sun and sleep for hours                                           Transferred to BPH DD unit – 3 months same
Unable to examine by GP                                           pattern
                                                             85                                                      86

                                                                         Gussepe’s action plan
 You are Gusseppe’s multi-discplinary team
 What Questions do you have re Gussepe ?
                                                                  What        When         Who          Time frame
 What are some of your hypothesis ?
 What are your ideas
Bio                   Psycho              Social
( medical wellness)   ( mental health )   ( life domains )

                                                             87                                                      88

 The Biopsychosocial Approach                                                        Trauma

 Recap                                                            Simple and Complex PTSD in people with
                                                                  Dual Diagnosis
 Challenging behaviour should be
 investigated not just managed
 Investigation should be based on a holistic
 approach and considered within the
 context of a persons unique abilities

                                                             89                                                      90
                      “Yassir “                                                   “YASSIR “
Grew up ion Gaza strip saw war first hand .                       Acute hospital admissions – in and out.
Was included in gangs who threw rocks at                          Transitions from Moms house usually evoked
each other                                                        aggression
Immigrated to Canada via Jordan (Mom ,                            Some food hoarding
Dad 2 brothers )                                                  Transfer to BPH DD unit - 3 years was
Aggression verbal ad property                                     stabilized at 1 year deemed ready for
Elopement – somewhat safe but not always                          community. No placements No agency
Police knew him and would drive him home                          involved.
Seen as unpredictable and “Scary”                                 Escalated quickly – Mom could catch it early
                                                                  and de escalate sometimes Described glare
Some placements – always broke down
                                                                  and rigidity as sign of escalation
                                                             91                                                     92

               Dotmocracy                                                  Yassir’s action plan
    You are Yassir’s-discplinary team
 What Questions do you have re Yassir?
                                                                   What        When        Who         Time frame
 What are some of your hypothesis ?
 What are your ideas
Bio                   Psycho              Social
( medical wellness)   ( mental health )   ( life domains )

                                                             93                                                     94

                          Stan                                                        “Stan “
 male                                                               Multiple assessments all disputing each other
 22 yrs old                                                         Disagreement on axis 1 only stand up is ADHD
 6’ tall                                                            Mild developmental disability – also disputed
 2 siblings sister learning disability, Brother                     Extreme cloak of competence – Can present
 schizophrenia 19yrs at onset                                       verbally an negotiate life . Understanding is
 History of family breakdown- non functioning                       limited – cognitive testing on comprehension
 Mother struggles with addictions, natural father                   very low
 abusive, step father history of incarcerations –                   Recently weighed in at almost 400lbs. Steadily
 aboriginal influence                                               increasing form about 180 at 17 yrs old
 CAS involved at age 4 all 3 children removed                       Many placements throughout CAS even sent to a
 form the house when Stan 7 , different                             treatment program outside of province
 placements                                                         Behaviorally described as “ bugging behaviors”
                                                             95                                                     96
                   “Stan “                                     You are Stan’s multi-discplinary team
  Incarcerated many times – physical aggression,           What Questions do you have re Stan ?
  sexual acting out
                                                           What are some of your hypothesis ?
  Suspected abuse as child physically and sexually
  not substantiated                                        What are your ideas
                                                          Bio                   Psycho              Social
  Pre mature grey hair                                    ( medical wellness)   ( mental health )   ( life domains )
  Many labels and myths – most services run

                                                    97                                                                  98

           Stan’s Action plan                                     High index of suspicion
                                                         Have more multiple and complex medical
                                                         problems Including epilepsy, vision/hearing
                                                         impairment, dysphasia, dental disease, obesity,
                                                         reflux disease, constipation, skin disease,
                                                         musculoskeletal disorders.
                                                         Unrecognized & under treated health conditions
What        When         Who          Time frame         including physical, dental and mental health .
                                                         lifestyle risk factors: (incl. poor nutrition, Vit. D
                                                         deficiency, low levels of exercise, osteoporosis.
                                                         Mental illness (greater risk and fewer resilience
                                                          medication: (include & over medication,
                                                         polypharmacy.                                    100

       Adjusting expectations                                  Strength based approaches
(Recognize that the client is presenting                    DRO
symptoms rather than being difficult… a shift               SRV
from being frustrated by the client to being                PSR
sympathetic to their situation. )                           Wraparound – BERS Assessment
Borderline Personality                                      Hope and Recovery
Bi Polar                                                    Harm Reduction
Anxiety                                                     PCS
OCD                                                         Normalization
Depression                                                  Others CBT DBT
                                                   101                                                                 102
Unique considerations when supporting                                       Best practice list
                                                             Assessment for understanding : severity/functional
 people who live with a dual diagnosis                      levels/adaptations skills, expectations. Chart Bio/psycho/social

   Cloak of competence                                      Exhaust Resources : access points navigation points
   Cognitive testing – variance in abilities
   functioning                                              Mental Health assessment : meaningful diagnosis
                                                            diagnosis/symptoms, effective Intervention ,alternative models i.e.
   Safe and unsafe situations – safeguarding                medical/psychosocial/recovery/role of hope ); potential impacts of
   Risk assessment- how to                                  pharmaceuticals .

   Trauma and abuse histories – stats                       evaluate outcome: plan/strategy/intervention through
   Diagnostic overshadowing                                 observation, multi-source feedback, user feedback and
                                                            documentation review
   Adaptations for communication counseling
   High index of suspicion                                  Relevant legislation/policy frameworks (i.e. Mental Health
                                                      103   and Health Care Consent Acts)                        104

    Biopsychosocial theoretical model: impact
   of psychiatric/medical problems on behavior,                 Communication Skills: with persons with a
   presentation & assessment of psychiatric illness             range of disability tailoring modalities and
   at various levels of disability; differential impact         devices,colleagual and mediation skills to provide
   of environmental variables and medication;                   effective support, advocate & clarify
   effective practice approaches with the range of
   challenging behaviors
                                                                Alliance Development: with user & family
                                                                respecting the value of feedback, perspective
    effective collaboration:cross-sectoral                      and goals, to ensure mutuality and reciprocity in
   practice. Options for adaptation of intervention             the relationship, shifting roles as necessary (from
   approaches to functional level and current life              advocate, to coach, to personal care as required)
   environments, positive behavioral approaches
   and crisis prevention/intervention and theory
                                                      105                                                               106

          Integrated aproaches
 People need to be treated in Holistic psycho-
 therapeutic way in order to move towards                                     Dual Diagnosis
 rehabilitation from MH
 Role of hope in recovery, hope to person hope to               “If there is no treatment individuals deteriorate “
 their support network .                                        “If a thorough assessment is met with treatment
 Cognitive therapy or others can be adapted and                 quality of life increases “
 modified to allow for the developmental disability             The definition of a useful diagnosis is one that
 Pictures, chaining events , cartoon bubbles,                   helps us with treatment so that a person gets
 catastrophizing, role-plays and Allowing for                   better”
 concrete examples I.e. sandpaper can represent
 wrong , cotton balls can represent right. Etc etc              Dr. Ruth Ryan
 Choice making as a skill                       107                                                                     108