Week 9 - Discussion: Multiple Facets of Dual Diagnosis and Systemic Approach to Assessment

timer Asked: Dec 30th, 2018
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Question description

After examining the assigned readings, complete Adult DSM 5 Self-rated Level 1 Cross-cutting Measure (link found in the Week 9 Books and Resources).

Submit a discussion post that addresses the following questions:

  1. What did you learn about yourself after completing the assessment?
  2. Describe your understanding of the Cross-cutting symptom measures, noting at least two main advantages of this type of assessment.

Cite at least three specific challenges presented by comorbidities and how you, as an MFT, will be able to address these challenges. Include references to the assigned readings.

Length: 350-400 words


Child and Adolescent Mental Health Volume 17, No. 3, 2012, pp. 153–160 doi: 10.1111/j.1475-3588.2011.00622.x Engaging with, and understanding children whose parents have a dual diagnosis Andrea Reupert,1 Melinda Goodyear2,3 & Darryl Maybery2 1 Monash University, Faculty of Education, PO Box 6, Clayton, Victoria 3800, Australia. e-mail: andrea.reupert@ monash.edu 2 Department of Rural and Indigenous Health, School of Rural Health, Monash University, Moe, VIC, Australia 3 The Bouverie Centre, La Trobe University, Brunswick, VIC, Australia Background: The perspective of children whose parents have a mental health and a substance use disorder (dual diagnosis) are rarely considered in either research or clinical practice. This study sought to (i) identify the issues when engaging children whose parents have a dual diagnosis into research, and (ii) present their needs and preferred supports. Method: Semi-structured, qualitative interviews were conducted with 12 children whose parent had a dual diagnosis. Analyses involved thematic analysis, inter-rater reliability and respondent validation. Results: Building trust with parents was crucial to gain access to children. Children described the importance of family, the secrecy around their parentÕs substance abuse, and various maladaptive coping strategies. Children requested more positive times in their families and specific support for their parentÕs substance abuse. Conclusion: The primacy of family in the childÕs life is highlighted. The need to acknowledge and work with the individual needs of children and parents, as well as family dynamics, is indicated. Key Practitioner Message: • Children living with a parent with a dual diagnosis are prevalent though largely neglected in research and practice • Engaging with parents in a meaningful manner is necessary before approaching children to participate in research about sensitive topics • Children require support in developing adaptive coping strategies and their parent needs specific support to address his/her substance abuse • Practitioners need to encourage parents to acknowledge the impact of their substance use on children • Practitioners should promote positive events and interactions within the family when a parent has a dual diagnosis Keywords: Family functioning; mental health; parent–child interaction; parent–child relationships; parental alcohol use Introduction It is difficult to obtain the prevalence of children whose parent has a dual diagnosis (co-morbidity of mental disorders and substance use disorders) though related statistics would suggest that it is high. The Office of Applied Studies (2009) found 11.9% of US children live with at least one parent who was dependent on or abused alcohol or an illicit drug during the previous year. Maybery and colleagues (2009) found that 21-23% of children have a parent with a mental illness. Conners et al. (2003) showed that depression (40%), psychological trauma (11.5%) and bipolar disorder (6.7%) were the most common mental health issues reported by women seeking treatment in 50 residential substance abuse treatment programs for pregnant and parenting women. Collectively, such data indicate that young people who have a parent with a dual diagnosis are a highly prevalent group within the community. Several quantitative studies have examined the impact of a parentÕs dual diagnosis on children (see Chassin, Rogosch, & Barrera, 1991; Dierker, Merikangas, & Szatmari, 1999; Hans, Bernstein, & Henson, 1999; Luthar et al., 1998; Stanger et al., 2002). For example, Luthar and Sexton (2007) investigated the impact on children of substance abuse and affective/ anxiety disorders across four groups of mothers (diagnoses of substance use only, affective/anxiety disorder only, dual diagnosis, and neither). They found that a psychiatric diagnosis was one and a half times as high among children in the maternal affective/anxiety only group as well as in the dual diagnosis group compared to the neither group. However, children whose mother had a substance use disorder only did not differ significantly from the control (neither diagnosis) group. Further analyses of the same data set showed mothersÕ stress and negative parenting behaviour (hostility, rejection, neglect, and lack of warmth) were more likely to be implicated in childrenÕs adverse outcomes than  2011 The Authors. Child and Adolescent Mental Health  2011 Association for Child and Adolescent Mental Health. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA 154 Andrea Reupert et al. maternal substance abuse and psychiatric disorder. Such data highlight the importance of a contextual approach when examining the issues for such families. We have not been able to locate any studies that consider the perspectives of young people living with a parent with a dual diagnosis and that provide them with a voice about their needs and issues. The lack of research mirrors also the lack of service provision. Psychiatric and other mental health staff generally work in a client centred manner, often without considering clientsÕ parenting responsibilities or the needs of dependent children (Maybery & Reupert, 2006). While there are several specifically designed programs for those with a dual diagnosis (Barreira et al., 2000; Drake et al., 2001; Tiet & Mausbach, 2007; Timko, Dizon, & Moos, 2005), these typically focus on the client alone, with little or no acknowledgement of dependent children. Programs that do acknowledge a clientÕs family tend to focus on adult family members and not children (Barrowclough et al., 2001; Mueser & Fox, 2002). Qualitative research with children living in similar contexts provides an indication of some of the issues for these children. Several interview-based studies with children whose parents have a mental illness have highlighted disruptions in the parent-child relationship, due to the parent being hospitalised and/or the child being involved in the parentÕs delusions (Maybery et al., 2005; Mordoch & Hall, 2008). Studies have found that some young people have several misconceptions about their parentÕs mental illness, for example, blaming themselves for their parentsÕ illness, or worry about ÔcatchingÕ the illness themselves (Cooklin, 2006; Fudge & Mason, 2004; Mordoch, 2010; Stallard et al., 2004). Another related group of research has investigated the perspectives of children whose parents abuse either alcohol and/or drugs. One of the main themes is the secrecy and denial around the parentÕs drug use, with the resulting message being Ônot to talk about itÕ within the family nor to Ôtell othersÕ outside of the family (Barnard & Barlow, 2003). As a result, many children are intensely loyal to their parents but at the same time shamed by, and actively dislike, their parentÕs drug taking behaviour (Backett-Milburn et al., 2008; Barnard, 2005; Barnard & Barlow, 2003; Fraser, McIntyre, & Manby, 2009; Moe, Johnson, & Wade, 2007; Orford, Krishnan, & Velleman, 2003; Templeton et al., 2009). A breakdown in family relationships and conflict, at times escalating into violence and abuse, are other features seen in families where a parent abuses alcohol/drugs (Kroll, 2004). There are overlaps with both groups of children including the caring responsibilities these young people assume, for themselves, their parents and/or siblings (Kroll, 2004; Maybery et al., 2005; Moe et al., 2007), in a process that Aldridge and Becker (2003) described as ÔparentificationÕ. The stigma associated with family members who have mental illness or substance abuse problems (Bancroft & Wilson, 2007; Reupert & Maybery, 2007) is another shared characteristic, as too are the disruptions to family relationships (Barnard & Barlow, 2003; Kroll, 2004; Mordoch & Hall, 2008). Different ways of coping or reacting to their parentÕs mental health or substance abuse have also been documented, including anger, worry, depression or acting out (Barnard & Barlow, 2003; Mordoch & Hall, 2008). Finally, being hyper-vigilant and always on guard are Child Adolesc Ment Health 2012; 17(3): 153–60 features some have identified in both groups of children (Repetti, Taylor, & Seeman, 2002). In order to develop appropriate interventions and supports, it is important to know how the experiences of children who have a parent with a dual diagnosis might differ from other young people. We have not been able to identify a study in which the voices of children living with a parent with a dual diagnosis have been shown. Service decisions, however, will be better informed and more likely to be utilised if the views of young people are heard and their views genuinely considered. As the difficulties in accessing a sample of children living with parents who are substance abusers has been highlighted (Barnard & Barlow, 2003; Kroll, 2004), another aim of this project was to document the methodological considerations when engaging childrenÕs participation in research. The aim therefore of this study is to document the process of engaging with young people who have a parent with a dual diagnosis, and present their experiences and preferred supports. Method The research was informed by childrenÕs rights, as highlighted by the United Nations Convention of the Rights of the Child (United Nations, 1989, p. 4): Ô... the child has the right to express his or her opinion freely and to have that opinion taken into account in any matter or procedure affecting themÕ. Accordingly, it was important to not only engage with children but to actively listen to what they had to say about their individual circumstances. While it was acknowledged that childrenÕs lives are constrained and influenced by the adults in their lives, children were regarded as having the ability to shape their social worlds and as capable of saying whether or not they wanted to be involved in the research (Prout, 2002). Theoretically, the research is interpretive, and presents the lived experiences and meanings of children regarding their families, as interpreted by the researchers involved in the project. Reflecting this interpretive framework, in-depth, one-to-one, semistructured interviews with children were employed to collect the data, followed by respondent validation (Kitto, Chesters, & Grbich, 2008), to allow for the negotiation of meaning between child and researcher. Recruitment The young people interviewed in this project were recruited through Northern Kids Care: On Track Community Programs, in Northern New South Wales, Australia, an organisation that specifically delivers services to families where a parent has a dual diagnosis. Families included those who had: 1. Dependent children currently living at least 20% of the time with parent/s; 2. A parent with a diagnosed dual diagnosis (co-occurring mental health and substance abuse diagnosis); 3. The parent had or was in the process of developing a Mental Health Plan (meaning that parents acknowledged mental health and alcohol/drug abuse issues); and  2011 The Authors. Child and Adolescent Mental Health  2011 Association for Child and Adolescent Mental Health. doi:10.1111/j.1475-3588.2011.00622.x 4. Children knew that their parent had mental health and alcohol/drug abuse issues. Ethics was obtained by university committee to interview children aged between 8 and 18. To be eligible in the current study, first parents and then their children had to provide consent. Consequently, where the parent was very unwell and/or hospitalised, the children were not eligible for involvement. This study was part of a broader study that investigated the needs of parents with a dual diagnosis (in preparation). In the first instance, parents were informed about the two components of the project at a monthly parent support meeting run by the service. We found that whilst many parents were happy to participate themselves, we initially received very few consent forms from parents for their children to be involved. Hence the interviewer (MG) started with the parent interviews. It was found that once parents had been through the interview process themselves, developed a relationship with the interviewer and felt comfortable about the process (including the opportunity to review transcripts and make changes), they were more comfortable about giving permission for their children to be involved. We need to be clear, however, that parents were not reminded during the interviews, or coerced in any way, about involving their children in the study. Thus, building rapport and engagement with parents is crucial; it should also be stressed that the engagement with parents was not tokenistic but involved regular and meaningful discussions about the research process and getting to know the interviewer in a relaxed, though professional, manner. This building of trust was far more involved than merely explaining the research process and providing information sheets, and meant that parents experienced firsthand the collaborative nature of the interviews. Nonetheless, there were still a sizable minority of parents who did not want their children to be involved. The 12 parents interviewed had in total 24 dependent children. Among this group, 4 parents did not provide consent to interview their 10 children, resulting in 14 children eligible for participation in the current study. Some parents were not keen for their children to discuss what they considered to be Ôfamily problemsÕ to ÔoutsidersÕ. Other parents believed that the process would be too distressing for their children. On occasion, some parents and their children were not able to attend pre-arranged appointments because of what else was happening in their lives (for example, eviction or subsequent periods of hospitalisation). Moreover, two children did not want to be interviewed, even though their parents had provided consent. Finally, finding appropriate interview times could be problematic as all young people were seen out of school time or on school holidays, for privacy reasons. Children whose parents have a dual diagnosis 155 asked questions about their parent and family life. We ascertained childrenÕs prior knowledge and readiness to participate from their parent and the case worker. The interviewer discussed the project individually with children, provided sample questions and answered childrenÕs questions. We were also clear about the possibility of children becoming upset or uncomfortable when discussing family issues. To ensure that potential participants felt in control of the process, they were told, ÔYou donÕt have to be involved in this interview if you donÕt want to be, no one will be angry with you if you decide you donÕt want to do itÕ (as recommended by Abramovitch et al., 1995). Children were clearly informed that involvement in the study had no impact on services. Issues of confidentiality were openly discussed at the recruitment phase and children were told that unless he or she was at risk or of harming someone else, no one, including their parents, would have access to what they said. No disclosures arose in the interviews that required notification. Engagement In this study, young people were repeatedly told that they were the ÔexpertsÕ in their lives, and that the interviewer hoped to learn from them (as per Singh, 2007). To build on the child-interviewer rapport already developed during recruitment, the interviewer found something to connect herself to each child and gave information about herself and so in this way was first a social person and, second, a professional with a distinctive and genuine purpose (Docket & Perry, 2007). Given the potentially distressing subject matter, the interviewer was sensitive to the verbal and non verbal cues of the young people, knew when to probe and when to back off, to offer further assistance and assurances and/or other professional support. At the conclusion of each interview the young person was debriefed and asked whether they had any concerns or wanted any additional support. Support personnel were available if needed, but were not requested. Interview The interviews were semi-structured with questions around ÔWhat it is like to live in families such as yours?Õ Interviews varied in length and content depending on the age of the child and what they were most interested to discuss. Initial questions were open ended about their family; however, if the child did not raise issues directly related to their parentÕs dual diagnosis, the interviewer openly asked: ÔSome families have additional issues when a parent has a mental illness and abuses drugs or alcohol. What has been your experience?Õ We believed that this prompt provided permission for children to talk about these issues but was vague enough so that children did not feel coerced into discussing family matters if they did not want to. Informed consent Whilst others have discussed the importance of children fully appreciating what research participation entails (Alderson, 1995; Cree, Kay, & Tisdall, 2002; Lind, Anderson, & Oberle, 2003; Masson, 2000), in this study informed consent meant that eligible children already knew that their parent/s abused alcohol/drugs and had a mental health issue, and understood they would be ChildrenÕs demographics The individual demographics for each of the children interviewed are outlined in Table 1. There were several sibling groups involved in the study, and parents had a range of mental health issues and substance abuse disorders. Diagnoses for parents and children were obtained from the parent and confirmed by the case  2011 The Authors. Child and Adolescent Mental Health  2011 Association for Child and Adolescent Mental Health. 156 Andrea Reupert et al. Child Adolesc Ment Health 2012; 17(3): 153–60 Table 1. Demographics of children interviewed Child Gender Age Child’s mental health Ethnicity Parent’s mental illness diagnosis 1 F 12 Diagnosed White Mother: eating disorder, Australian PTSD and anxiety anxiety, self-harm 2 M 12 None identified 3 M 15 None identified 4 M 14 None identified 5 M 8 6 F 11 Diagnosed with generalised anxiety disorder None identified 7 F 8 None identified White Mother: bipolar Australian 8 9 M F 13 11 None identified None identified White Mother: bipolar Australian and depression 10 M 13 None identified 11 F 12 None identified White Mother: Australian depression White Mother: Australian depression 12 F 11 None identified Parent’s substance use Mother: painkillers; past narcotic abuse White Step father: bipolar Step father: marijuana Australian and ADHD and alcohol White Australian Aboriginal Father: bipolar Father: marijuana and ADHD and alcohol White Father: Australian schizophrenia Father: alcohol and marijuana White Mother: anxiety, Australian depression, OCD, agoraphobia Mother: marijuana, past heroin use White Mother: bipolar, Australian PTSD, anxiety and panic attacks manager. Ten of the children lived with their parent full time, while two siblings lived with their parent 50% of the time. Data analysis Data were analysed according to Interpretative Phenomenological Analysis (IPA: Smith, 1996; Smith & Osburn, 2004). IPA is an approach that seeks to identify participantsÕ lived experiences and the meanings that participants hold for those experiences (Smith & Osborn, 2004). One of the authors attached labels to lines or paragraphs of data, and then described the data at a concrete level (Anfara, Brown, & Mangione, 2002). Focused coding followed, which moved the coding process to a conceptual level, from which categories were created and named (Constas, 1992). At this point, the identified categories and original transcripts were shown to each child, in another interview (respondent validation: Kitto et al., 2008). Children were invited to comment further and to delete or change anything they Other information Only child. No father present. Involvement of child protection. Child later removed from mother. History of domestic violence and sexual abuse. Ten children living at home, with biological mother. Same home as for child #2 and 3, but this child is step-son of mother of child #2 and #3. Eldest of three children. Mother present. Has older sister, who was extremely violent but no longer lives at home. Lives with mother – custody shared with grandmother. Father not present. Mother: marijuana Has a younger, 3-year-old sister with developmental delay. Father not present. Mother: heroin No father present – mother and alcohol has partner living with them. Grandmother strong support to family. Mother: marijuana and Eldest of three children. alcohol binge drinking No father present. Mother: alcohol Two older siblings aged 21 binge drinking and 23, all live with mother. Also an older brother diagnosed with bipolar disorder – recently committed suicide. No father present. Mother: marijuana Lives with mother mostly but at times lives with father and grandmother. felt was inaccurate or potentially identifying. After incorporating childrenÕs feedback, the first two authors independently identified categories across individual transcripts. Rather than come up with an index of agreement, consensus was reached through discussion between the two authors, who at this point constantly referred back to the original transcripts. In this way, the shared experiences of children were highlighted, as well as unique occurrences. Results Four interrelated themes were identified including: (i) meaning of family; (ii) understanding the parent and his or her ÔillnessÕ; (iii) coping and reacting; and (iv) preferred supports. Meaning of family In one way or another, all children described how important their family was to them.  2011 The Authors. Child and Adolescent Mental Health  2011 Association for Child and Adolescent Mental Health. doi:10.1111/j.1475-3588.2011.00622.x We [mother and child] have a close bond. (11-year-old girl) Everyone is kind in my family... I like to play with my sister. (8-year-old girl) However, all children also described the problems that their family faced, particularly in regard to Ôa lot of fightingÕ (12-year-old boy) with other comments including: Children whose parents have a dual diagnosis 157 Some children focused primarily on their parentÕs drug use as an issue of concern, especially in terms of their parent hiding it from them. She (mum) tries to keep the stuff private (marijuana) and away from me, but I know about it. (11- year old girl) SheÕs always in her room when [she] is doing it. You donÕt get to see her. I wish she wasnÕt taking drugs. I get angry when sheÕs doing it. (13-year-old boy) Living in this family – fights often happen. When mum and dad get stressed, we get in trouble and sometimes it all goes too far. (15-year-old boy) The two children whose father had a dual diagnosis independently described him ÔangryÕ. When my mum gets stressed she swears and hits the kids if they are naughty... we get yelled at a lot… (14-year-old boy) Sometimes he (dad) loses his cool more than other dads... you have to not argue and just take it. (15-year-old boy) All the children interviewed described how their family needed to improve. For the young people interviewed, the focus was not so much on improving things for themselves as individuals; instead young people wanted support for the family to do things together in a positive manner. He gets angry when he is drinking. You have to be careful. (8year-old boy) We need more time to have fun and play in the family, especially with dad (who has the dual diagnosis). (15-yearold boy) I want to spent time with my family but the tension makes that time difficult and people in the family especially mum gets stressed. (12-year-old girl) Coping and reacting There were various ways that children reported coping with their parentÕs dual diagnosis, including: ...when mum is ill, I get stressed and start eating. I donÕt want to do that and get unhealthy. (12-year-old girl) I worry about her. (11-year-old girl) It doesnÕt really affect me. My brother is affected but... he gets angry and has his own mental illness. (12-year-old girl) When describing the good things in their lives, inevitably many described doing things as a family or some form of parent-child interaction. In reaction to their parent, several children described the need to be ÔgoodÕ. [I like it] when my mum will watch me swim. (12-year-old girl) I try not to muck up and do as youÕre told... you need to be yourself and be good... I tend to tune out from them [the parents]. (15-year-old boy) I feel happy when we are all together and doing stuff. (14year-old boy) ItÕs important that I am good and not make dad angry. (8year-old boy) Understanding the parent and his or her ÔillnessÕ Many of the children described having to look after themselves, their siblings and/or their parent. The cue of familial mental illness and substance abuse prompted children to elaborate what they considered to be their parentÕs ÔillnessÕ or ÔsicknessÕ. This was described by many children in terms of their parent being emotionally as well as physically unavailable. ... when you want to do stuff with friends, you canÕt go out and have fun, you have to stay at home and look after mum. (12-year-old girl) Mum [is] sick all the time. It can be hard to look after her and [this] puts stress on me sometimes when it is bad. When you go to the fun parks she canÕt join in on rides... when your parent is sick they donÕt have much time for you to show you attention or anything... (12-year-old girl) In response to these caring responsibilities a 14-yearold boy asserted ÔIÕm only a kid – I want to do kid stuffÕ. She (mum) is in the bedroom all the time. (11-year-old girl) She has to go to rehab and she is going away a lot. My grandmother takes care of us [then]. (13-year-old boy) You canÕt always talk to mum when you want to. (13-yearold boy) Some children were not able to distinguish between the impact of their parentÕs mental illness and substance abuse: ... donÕt know if itÕs the drugs or the mental illness, but he just sleeps in a lot and he is not there. (12-year-old boy) Alternatively, other children were clearer about the difference: ItÕs more her mental illness [mother has anxiety, depression, OCD and agoraphobic] that worries me than the drug abuse. (11-year-old girl) I help look after my little sister when mum needs a break. (8year-old girl) Preferred supports Young people were asked to nominate the types of supports they would like to see, if any. All reported that their family needed support to become closer and more connected. We need to get along better. (13-year-old boy) We need to do more activities together, so that you can have a good time and become closer. (12-year-old girl) Some children said that they needed the opportunity to talk to someone about their feelings: My friends at school help out... I like getting away from home. (12-year-old girl) Having friends to talk to would be good... itÕs weird having a mum like mine... my friends donÕt... and IÕm the odd one out… I donÕt talk about it much with them [friends] and I donÕt get a chance to talk about it at all. (11-year-old girl)  2011 The Authors. Child and Adolescent Mental Health  2011 Association for Child and Adolescent Mental Health. 158 Andrea Reupert et al. At the same time, an 11-year-old girl said: I can talk to people but it doesnÕt really help. Getting out of the house helps. Mum just needs to change. Another 12 year old girl specifically asked for support in managing her mother: [I need] someone who could come and talk regularly about how to help my mum more and not just to keep it [the substance use] going. Many of the children talked about the need for more money to Ôdo more fun thingsÕ Ôto buy a bigger houseÕ Ôwe need a new house, this one is too small and run down and has too many cockroachesÕ. Other quotes include: You are always broke as money is needed for food and clothes, so you miss out on stuff. (15-year-old boy) We need more money so we can do more fun things together. (12-year-old boy) An 11-year-old girl stated that her mother needs a car Ôto get around town... to pick up things like medication and shopping but also so we can do fun things together... because we donÕt do thatÕ. Many children were unequivocal about wanting their parent to stop using drugs and/or alcohol. IÕd be happier if mum stopped taking drugs and alcohol and we had a bit more money. (13-year-old boy) We need to change what mum does... Mum needs to stop taking drugs. (11-year-old girl) Discussion Young people, living with a parent who has a dual diagnosis, have lives that are complex and multifaceted, and unique to each family and individual. Methodologically, the study demonstrated the importance of first developing trust and rapport with parents, over a substantial length of time, when recruiting children into research regarding sensitive topics, as well as fully informing children about the research process and outcome. It also needs to be acknowledged that research with these populations requires a great deal of time and effort for relatively small sample sizes. At the same time, the information presented here provides a window into the needs and experiences of an often neglected group of children. The themes identified here overlap considerably with the presentations of other young people living in similar families. ParentÕs secrecy around their substance use, reported in other studies (Barnard & Barlow, 2003; Kroll, 2004), was also found here. The various maladaptive coping strategies (e.g. overeating) and the additional caring responsibilities identified mirror the experiences of other children living with parental mental illness or substance abuse (Maybery et al., 2005; Moe et al., 2007; Mordoch & Hall, 2008). Thus, children whose parents have a dual diagnosis are similar to other children whose parents have a single diagnosis, in terms of their experiences and needs. Importance of family togetherness was a significant finding of the present research not obvious in previous research; even though young people simultaneously acknowledged many problems and wanted things to change in their family they still wanted to be together. Child Adolesc Ment Health 2012; 17(3): 153–60 This is an important finding and one that appears to be unique to the current study. Such a finding highlights the importance of recognising the primacy of family in the childÕs life and the need to encourage positive events and positive interactions in families. Children nominated a range of preferred supports, though these tended to be individualised. For instance, some wanted the opportunity to talk to others, while another said that talking did not help. Financial support was commonly expressed, suggesting that childrenÕs needs should be recognised within broader forms of disadvantage. It is also important to note that children wanted support for their whole family and specially their ÔillÕ parent, in terms of drug/alcohol abuse, rather than for themselves. Practitioners need to encourage parents to acknowledge the impact of their substance use on children. A limitation of this study was that the young people interviewed were identified from a specific location and drawn from an organisation that was providing a service for them and their families. Other groups of young people, particularly those whose parents are not being supported, might well have different perspectives. Given that we included only those young people who knew about their parentÕs diagnoses, results of the study may not generalise to others who have no such knowledge. The number of sibling groups involved in the current study also means that some families were over represented. Additionally, it is difficult to disentangle the direct impact of a parentÕs dual diagnosis on children because of the environmental variables often associated with living with mental illness and substance abuse such as poverty, marital discord, isolation and housing instability (Repetti et al., 2002); this can also be seen in the complexities of the childrenÕs family relationships and living arrangements (Table 1). Reducing the experiences of these children to their parentÕs dual diagnosis is not our intention. Instead, we sought to understand how certain family characteristics, and in particular living with a parent with both substance abuse and mental health issues, might be perceived by young people. Moreover, a parentÕs diagnosis, and entry at either psychiatric or drug and alcohol services can be an opportune time to identify the presence of dependent children, and their own subsequent needs. Thus, within the limitations of a small and biased sample group, this study has been able to provide some indication of what these needs are and what services might be able to offer. In conclusion, this study is important as it is the first to offer perspectives of children living with a parent with a dual diagnosis. Future studies might consider the needs of children living with parents with a dual diagnosis who are not being supported, and across various developmental domains (for example, comparing the experiences and needs of young children and older children). More accurate prevalence data are also required. At the same time, in the current study childrenÕs views highlight the need for community based, multidisciplinary teams that meet the needs of parents with a dual diagnosis as well as the needs of children. The study stresses the importance of working with the whole family, including children (enhancing coping strategies) as well as parents (focusing on substance abuse). Targeting family  2011 The Authors. Child and Adolescent Mental Health  2011 Association for Child and Adolescent Mental Health. doi:10.1111/j.1475-3588.2011.00622.x dynamics, including the enhancement of positive interactions, is also indicated. Acknowledgements This research was supported by theCommunity Based Mental Health Program through FaHCSIA, the Ian PotterFoundation and the Mental Health Coordinating Council of NSW. The authors have disclosed that they have no competing or potential conflicts of interest. 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bs_bs_banner Journal of Policy and Practice in Intellectual Disabilities Volume 10 Number 3 pp 230–235 September 2013 The Challenge of a “Triple Diagnosis”: Identifying and Serving Homeless Canadian Adults With a Dual Diagnosis Donna C. Lougheed and Susan Farrell University of Ottawa, Ottawa, ON, Canada Abstract Adults with both a mental illness and intellectual disability (in Canada, a “dual diagnosis”) and who reside in shelters for the homeless are vulnerable and at risk for physical, sexual, and financial abuse. The same factors that make them vulnerable may result in neglect by the very services designed to help them. Their mental illnesses are difficult to diagnose and treat, and their intellectual impairments are difficult to ascertain. The authors review the existing literature on homelessness and intellectual disability, and use this and their extensive clinical experience with the homeless in a large Canadian city to identify and extrapolate reasons for the challenges facing both these individuals and the agencies and organizations that serve them. The authors identify several challenges to providing appropriate services, such as identifying and linking with these adults; recognizing the implications of the level of the intellectual delay and the mental illness on the individual’s ability to cope, and stay safe; understanding the wants and needs of the individual; expanding the mandate of the agencies and professionals wanting to serve this group; and developing policy that will both provide appropriate support of the individual, but also provide protection, if necessary by legal means. They further suggest that focal services should be based on the following characteristics: flexibility, meeting the client where he or she lives, consideration of capacity to consent in order to avoid neglect issues, and understanding of the lifelong and pervasive effects of intellectual delay in all facets of life. Though the population discussed is resident in Canada, these issues apply to individuals in other countries, as well, where there are concerns about these vulnerable adults with a “triple diagnosis.” Keywords: dual diagnosis, homeless persons, intellectual disability, mental illness, vulnerability INTRODUCTION The Canadian system of comprehensive social support and universal healthcare can still not prevent homelessness or its associated vulnerabilities. Although there are many pathways into homelessness, agencies that provide support to mentally ill homeless adults recognize that there is a subgroup of homeless individuals who are even more vulnerable, hard to serve, and at risk of abuse and neglect. These are the homeless adults with intellectual disability (ID). The reasons that men and women with ID become homeless and continue to be homeless in Canada, despite the availability of free outreach social and medical services, are poorly understood and challenging to clarify. Research on identification of and effective treatment of adults with mental illness and intellectual impairment is limited. Fletcher and his colleagues have reported that the 2 to 3% of the population who have an ID have an incidence of mental Received July 18, 2012; accepted July 9, 2013 Correspondence: Donna C. Lougheed, MD, Medical Head, Dual Diagnosis Consultation Outreach Team, Royal Ottawa Health Care Centre, Community Mental Health Program, Suite 2000, 320 Catherine St, Ottawa, ON, Canada K1R 5T5. Tel: +1 613 722 6521 ext. 7128; E-mail: dclougheed@yahoo.com illness somewhat greater than the general population (Fletcher, Loschen, Stavrakaki, & First, 2007). Canadian researcher Burge (2009), when discussing challenges facing adults with ID, noted that “cognitive and functional impairments are often compounded by stressors related to communication difficulties, socioeconomic disadvantages, inadequate housing and supervision supports, lack of access to case management and vocational services, and wide-spread discrimination.” The authors’ clinical experience with homeless adults and with the agencies that serve them reinforces the belief that this is a challenging group to recognize, understand, and to serve. There is limited research to guide goals and services planning. IDENTIFICATION OF ADULTS WITH A DUAL DIAGNOSIS IN THE HOMELESS POPULATION ID in adults is only sometimes recognized clinically by service providers in homeless shelters. From a formal evaluation research perspective, little is known about needs and challenges of this population. Clinically, as a group they appear to be extremely vulnerable, and more at risk for financial, sexual, and emotional abuse and neglect than other homeless adults. They may have symptoms of mental illness, but it is not clear © 2013 International Association for the Scientific Study of Intellectual and Developmental Disabilities and Wiley Periodicals, Inc. Journal of Policy and Practice in Intellectual Disabilities Volume 10 Number 3 September 2013 D. C. Lougheed and S. Farrell • The Challenge of a Triple Diagnosis how often these illnesses are primary (existing prior to and contributing to the cause of homelessness), such as a psychotic disorder, or secondary to (due to) homelessness, with its accompanying stressors of abuse and neglect, exposure to street drugs, and confusion due to lack of appropriate support. In a recent literature search using keywords of “homelessness” and “developmental delay,” very few reports were identified, which reported on developmentally disabled individuals in the homeless population. The majority of the reports, from the United States, looked at developmentally delayed children who were living in shelters with a parent (Chiu & DiMarco, 2010; Fox, Barnett, Davies, & Bird, 1990; Rubin et al., 1996; Zima, Wells, & Freeman, 1994). Oakes and Davies (2008) from Great Britain reported an attempt to determine the prevalence of ID in a group of 50 adults in a homeless shelter. After testing, the authors determined that IQ was significantly lower than would be expected in the general population. A 2009 Canadian review by Burra, Stergiopoulos, and Rourke (2009) looked at the prevalence of cognitive deficit in homeless people in 22 published studies of homeless adults. Those studies using the Folstein Mini Mental Status Exam reported that between 4 and 7% had cognitive deficits. However, the report did not specify whether the deficits were due to intellectual delay (which by definition exists prior to age 18), or another reason (such as traumatic head injury or alcohol-related dementia) after the age of 18. Farrell (1999) reported on 230 homeless men and women not screened for ID in five Canadian shelters. Average age was 38 (40% were women) and 60% reported having a mental illness. They found that 12% reported stopping school at Grade 8 or less (in Canada generally completed by age 14), despite secondary school education being free to age 21, and compulsory to the age of 16. These individuals reported an average length of stay in the shelter of 235 days; 15% had spent more than 1 year homeless. Farrell and Lougheed (2012) reported on a review of 800 charts of a multidisciplinary psychiatric outreach team, which served homeless adults with mental illness in a major Canadian city. Clinical staff identified at time of early contact that 5% of clients had a dual diagnosis. The authors reported this to likely be an underestimation due to the difficulties clinical staff experience identifying with accuracy this subgroup of the shelter population. Clinically, it was noted that there were significantly cognitively impaired adults living in the homeless shelters, especially in the older population. The etiology of their cognitive impairment was not invariably intellectual delay but also included organic brain syndrome secondary to traumatic brain injury, alcohol abuse, or another dementing process. DUAL DIAGNOSIS: INDIVIDUALS WITH MENTAL ILLNESS AND INTELLECTUAL DELAY IN THE SHELTERS Clinically, it appears that there are limited services available to support adults with mild or moderate ID in the community, whether they live in their parents’ homes, or in semiindependent or independent living. When there is a breakdown in the living situation, there are few social support services available to prevent the journey to homelessness and the shelters. Homeless shelter managers have reported that the numbers of intellectually impaired adults using shelters is growing. They do not feel they can accurately identify this group and their needs, or provide adequate support services (Muckle, 2012). Homeless adults with ID may have engaging social skills or facile verbal abilities, or an irritable, challenging personality that keeps others at a distance. They may have lost their previous housing due to difficult behavior directed at family or landlords, or have drifted into the shelter system after staying with friends (often called “couch surfing”). They may have challenges with budgeting or accessing welfare due to poor reading and writing skills. They may have difficulty maintaining working relationships with healthcare or other service providers due to their challenging personality. Financial skills are often poor, with credit not understood, a lack of awareness of basic budgeting, and bank machines seen as “free money machines” and not as gatekeepers to bank accounts that need to have money deposited. It has been observed clinically that adults with intellectual delay and mental illness appear to access psychiatric care in the general hospital emergency departments. The emergency room nurse or physician is usually not skilled in screening adults to identify mild and moderate cognitive impairment. These patients do not offer this information readily, often because of stigma issues. The adult with mild or mild–moderate cognitive impairment may present to an emergency department with unstable affect and regressed behavior, and may threaten selfharm. These patients are sometimes given the diagnosis “Borderline Squared,” referring to both their problematic and challenging personality characteristics (similar to borderline personality disorder) and their “borderline” or mild ID (C. Mann, personal communication, 2012). They are often victims of “revolving door” presentations to the emergency department, and are described as “not following the plan.” Mental health professionals who have little experience with adults with ID may not be aware that these highly stressed, poorly functioning individuals have difficulty keeping track of phone numbers and their own healthcare cards, have no access to bus tickets or money, and may not know how to get to the hospital outpatient department, let alone be at risk of ongoing abuse at the shelter. Hospital staff standardly have no access to previous cognitive testing (IQ) results and are not trained in bedside assessment of cognitive ability. A commonly used clinical technique to identify cognitive disability, assessment of the patient’s language skills, is inadequate when there are emotional issues or second or third language issues compounding the assessment (as in major urban centers in bilingual Canada, and with immigrant or refugee populations). Appropriate community services, including supportive housing or day/activity programs, are not quickly or easily available. There may be lengthy waits for assessments by agencies that provide the gateway to starting or increasing developmental sector service support. If these patients are hospitalized in an inpatient psychiatric unit, physicians anecdotally report they can be challenging to discharge in a timely manner to appropriate supportive housing, and so they are discharged back to the shelter. IQ testing by a psychologist, often necessary to access adult developmental sector services, is not often available due to lack of psychological resources. This is despite the need for documentation of “mental retardation” using numerical IQ results in some Canadian jurisdictions for access to service provision. 231 Journal of Policy and Practice in Intellectual Disabilities Volume 10 Number 3 September 2013 D. C. Lougheed and S. Farrell • The Challenge of a Triple Diagnosis CHALLENGES FACING THE ADULT WITH DUAL DIAGNOSIS IN THE HOMELESS SHELTER SYSTEM Substance abuse, mental illness, and personality issues in other shelter residents often create an atmosphere that is threatening and stressful for the adult with dual diagnosis. Clients are at risk of verbal and physical assault, and theft of money and belongings. They have limited personal space (often living in quarters with upwards of 30 in a room), and lack access to quiet space. Drugs of abuse are easily available, as are sex trade opportunities. These factors combine to create a milieu that can be frightening, and encourages defensiveness and distrust. It can also result in poor choice of acquaintances in the individual with high affiliation needs. In an individual at risk for anxiety or depressive disorders, lack of sleep and constant worry provide triggers for the development of mental illnesses. High level stress in an adult with an ID may result clinically in a picture of psychosis due to behavioral and emotional regression. The individual who arrives at a shelter with a preexisting mental illness has little opportunity to seek or continue treatment, and is at high risk of exposure to conditions that can worsen the illness. Poor functioning in the homeless person with a dual diagnosis can have several etiologies: a mental illness, a developmental delay, lack of support, and living in a chaotic environment, or an interaction among all of these. The cognitive impairment itself may result in difficulty learning and immature judgment (due to decreased executive function, and impairments to decision making skills). Examples of poor judgment are reflected in client comments such as “I don’t have any problems,” “you can’t tell me what to do,” “but this (the shelter) is my home,” “I guess I’ll go stay in the [convenience store] all night,” and “I don’t care if I go to jail—at least the staff there are nice to me.” These developmental age typical levels of reasoning are often understood by social services or healthcare professionals to reflect choice, stubbornness, or “behavior” (a vague term used both in the developmental sector and the mental health sector). There is an implication that the “behavior” or statements that are willfully being used to manipulate others are based on “informed choice” and reflect poor motivation to change. However the statements may in reality reflect long-standing and impaired cognitive reasoning that will not “get better” if staff ignore them, or if the individual experiences negative consequences. The immature reasoning may result in actions that are dangerous without an understanding or appreciation of the danger, such as financial loss, physical assault, sexual abuse, or legal charges. Shelter and outreach staff may become angry or discouraged due to interactions with clients with an angry demeanor, and the client may have difficulty maintaining a working relationship with healthcare professionals. These challenges may contribute to the loss of permanent housing, or frequent change of shelters with resultant instability in services. RESPONDING TO THE NEEDS OF HOMELESS PEOPLE WITH DUAL DIAGNOSIS Homeless adults with a dual diagnosis appear to require a different kind of support from the general shelter population, in 232 order to move out and stay out of shelters successfully. This appears to be due to both the cognitive deficits associated with their intellectual delay, as well as their challenging personality defenses, which may have developed as coping strategies, or be aggravated by preexisting mental illness. Though this conclusion is based on clinical experience rather than research, it is evident clinically this population experiences challenges accessing services that are available and to which they are entitled. When the adult also has a mental illness (whether it be an adjustment disorder due to environmentally related stressors, or schizophrenia), he or she may regress to a more immature level of functioning. This makes it more challenging for the healthcare professional to understand and appreciate baseline (best previous level) functional strengths and weaknesses. The client who is offered support that does not recognize baseline function may start to avoid the support person or professional who offered it, because of fear of being criticized or blamed for not following directions they did not understand or did not have the skills to accomplish. These clients may present with an inability to trust authority figures because of negative experiences in the past: for instance, with children’s aid organizations when they were young, school teachers and principals, police and transit authorities, and security guards in malls. This lack of trust of people in positions of authority may generalize to their not being willing to trust healthcare outreach workers who approach them to offer help. Information on identifying and responding to the challenges to providing diagnosis and treatment of mental illness in adults with developmental delay is not widespread, and tends to be what is described in the literature as “evidence-informed” rather than “evidence-based” (Whitley et al., 2011). Few studies address interventions for the homeless population. A Canadian study by Bedard, Drummond, Ricciardi, and Husband (2003) described a women’s support group model that provided help with coping skills for homeless or poor women. Farrell, Huff, MacDonald, Middelbro, and Walsh (2005) described an outreach model that provided assessment and support to adults in shelters, but this was not specifically directed at adults with developmental delay. CHALLENGES TO PROVIDING SERVICES: ISSUES AROUND ABUSE AND NEGLECT Professionals in the field of developmental disabilities are aware of the concept of “cloak of competence.” However, this concept is not known to generic professionals. Cognitive deficits are frequently not identified in adults with borderline and mild intellectual ability. Lack of expertise may result in professionals with little experience making false assumptions about their clients’ ability to follow directions, complete tasks, read instructions, manage money, and assess trustworthiness in others. This may result in further experiences of failure by the client and the inappropriate and unhelpful label of “noncompliant with treatment recommendations.” Despite clinically apparent cognitive impairment of any etiology, this population in the shelter system is often not identified as needing significant intervention, as reflected by the paucity of assessments of capacity to consent or refuse treatment, whether considered, performed, or recorded by healthcare professionals. Journal of Policy and Practice in Intellectual Disabilities Volume 10 Number 3 September 2013 D. C. Lougheed and S. Farrell • The Challenge of a Triple Diagnosis This may be despite the individual’s challenges recognizing and managing both significant mental illnesses and physical illnesses such as gall bladder disease or diabetes. Homeless adults with dual diagnosis appear to become at risk of neglect and abuse by helping services due to several factors. These include a “romantization” of homelessness as a choice; the sometimes inappropriate expectation by professionals that individuals of “limited ability” be “allowed” to make poor choices; and the disregard by professionals of the cognitive challenges to ability to assess risk that defines the impairment associated with developmental or intellectual delay. The intellectually impaired client may have problems with calculating (estimating or anticipating) risk. This may result in “friends” being poorly chosen from available shelter or street acquaintances. The client may be unable to predict that the action he or she is about to undertake is dangerous: for instance, sleeping outside in the winter, at the side of a road, or in a parking lot, behaviors the homeless often resort to. Guidelines for what constitutes neglect and when to intervene are also not well described, with different groups of professionals having different perspectives. There is limited consensus clinically on what amount of risk is acceptable before it is identified as neglect or abuse. There is little agreement by professionals on using and applying capacity to consent assessments, whether it be for finances or for personal care, based on finding of functional impairment and level of ID. This may be because of clinician concerns about appropriate housing not being available and hospitalizations being either not helpful or overly long, or a belief that shelters can provide more support than they do. Clinically, it appears that homeless women with an ID may be particularly vulnerable to abuse due to their significant affiliation needs (the desire to have friends, to feel wanted, to be part of a group, or to have a “boyfriend” or “husband”). This can result in serial or multiple sexual relationships, financial and physical abuse, participation in prostitution and other sex-trade activities, and substance use and abuse. Although seen clinically, objective data on the extent of the problem or appropriate effective interventions are not available at this time. Unfortunately service providers may be unknowingly contributing to neglect and abuse in this population. Traditionally, in psychiatry, areas of personal decision making are considered as encompassing three areas; decisions in the areas of personal medical care, financial decisions, and decisions about place of abode. Adults who are homeless often have challenges in these areas. Supportive agencies often help adults with finding shelters; however, it can be difficult to leave the shelter to find permanent housing, for reasons that have to do with both symptoms of mental illness as well as cognitive abilities and personality issues. This can lead to issues of what might be considered neglect and abuse by the agency. For instance, staff will sometimes attempt to help their client by taking over the care and supervision of government checks, for well-intentioned reasons (e.g., to keep the person from being assaulted for his money). Staff taking a client’s personal belongings into care appears to happen less, for reasons that are not clear—however, possessions end up being stolen too, so the rationale is unclear. There appear to be rules and guidelines prohibiting shelter staff from doing this, possibly to protect the shelter from false accusations of theft. Adults staying in homeless shelters often do not have access to storage or personal spaces, and must vacate the premises during the day, even in winter. There is an expectation that clients’ medications are routinely kept by shelter staff at a front desk due to internal policy. This effectively cuts down on medication sharing, stealing, or overdosing, but does provide challenges around autonomy, as well as access if the individual moves elsewhere suddenly. Mentally ill adults may leave the shelter without proper clothes, or without medication and belongings, and spend the night outside or not return at all. Staff are often reticent to report this to the police as a “missing person” event, or to go to the justice of the peace to obtain a mental health form, which would allow the individual to be taken to the hospital for a psychiatric assessment, despite the risk posed by the behavior associated with the mental illness. These acts and others, while well-meaning, may constitute abuse and neglect of the adult with ID, specifically by the social and healthcare systems, which do not recognize these deficits, and therefore do not properly protect by the legal means available, by assessing and respecting capacity issues. Significantly, there are limited resources available if the person is found incapable or in the need of support in the community, for minimally invasive interventions, such as access to case management, appropriate housing with developmental system support, or safe day programming that can deal with the behavior challenges of seemingly streetwise but vulnerable adults. It is of concern that the local developmental disabilities agencies appear to be overwhelmed by the needs of the many adults who have been moved into the community system with the closure of institutions for adults with ID. In one locale in Canada, some 270 adults were transferred to placement in their local urban community over a 5-year period (Lougheed, 2006). This transition resulted in a limitation on new services for those who were marginally served by community agencies before, or those who were supported by their families, until with the natural progression of life with aging parents, development of significant medical illnesses, or family breakdown, they required new or expanded services. CHALLENGES AND OPPORTUNITIES The principal of integration of services and treatment for adults with ID within the general population is desirable as a general principle; however, it is not always appropriate or adequate for many individuals. The adult with dual diagnosis who is homeless appears clinically to require specific targeted services. There are several challenges facing agencies and organizations. The first is identifying and linking with these adults; the second is recognizing the implications of the level of the intellectual delay and the mental illness on the individual’s ability to cope, and stay safe; the third is understanding the wants and needs of the individual; the fourth is expanding the mandate of the agencies and professionals wanting to serve this group; and the fifth is developing policy that will both provide appropriate support of the individual, but also provide protection, if necessary by legal means. 233 Journal of Policy and Practice in Intellectual Disabilities Volume 10 Number 3 September 2013 D. C. Lougheed and S. Farrell • The Challenge of a Triple Diagnosis Information that can inform appropriate management is gathered initially by clinical observation, often followed by consensus discussion and agreement by experts in the field, ultimately resulting in substantiation by good caliber research. However, gold-standard “evidence-based” data are difficult and expensive to obtain, especially when the clinical population is found in shelters as opposed to university-affiliated health clinics. At this point, clinical observation guides much of our understanding as well as our interventions until appropriate data collection. Conducting field research can also present challenges. Individuals may not read well enough to understand consent forms (which often require a Grade 6 reading level). They may hesitate to sign a consent form, to complete a questionnaire even if it is read to them, or even refuse to meet with the researcher. The researcher may not find it practical to contact a substitute consent giver. One way to obtain information on consumerinformed understanding of the challenges faced by these adults might be to hold focus groups of invited adults with ID in the shelters. Though this may not be a representative group, helpful information can be obtained. Morton and Cunningham-Williams (2009) looked at predictors of homeless adults’ capacity to give consent, and noted the most accurate factor was Grade 8 education. They reported that chronic homelessness, and a diagnosis of intellectual disability were also predictors, but with less weight. McCreary, as well as other Canadian authors, have advocated more and better follow-up of these adults (Burge, 2009; Lougheed & Farrell, 2007; B. D. McCreary, 2005). Follow-up services should be aware of and provide support to the social, affiliation, financial, medical, and psychiatric needs of adults with mild and moderate delay who are living in fragile situations. Elements of this support should include time-unlimited and possibly lifelong service. These adults are at risk of recurrent decompensation if significant support is withdrawn, or if they face challenges such as a new and serious physical illness such as diabetes, or a relapse of a significant mental illness such as a mood disorder. An option for serving adults who are homeless may include a model called “wrap-around mental health case management.” Legal charges may be decreased by community supports and services that provide easily accessible meals, recreation, and informal supervision to encourage healthier community and peer involvement. Programs can include modification of standard court diversion for individuals with a mental illness who have been legally charged. There should be easy access to developmentally appropriate programs that support financial planning and management to help with basic budgeting, understanding the risk of credit, tips to discourage borrowing or lending money. It is important that these programs not be literacy based, but rather “plain-talk” based. To avoid financial abuse of extremely vulnerable adults, there should be provision of easier community access to financial capacity assessment. There may be a need for consideration to be given to new laws making it mandatory for professionals to report suspected abuse and neglect of developmentally delayed adults, as is present in the Child Welfare Act for children up to the age of 16 in Canadian provinces. Supportive housing should have a community integration focus, to allow safe community involvement and encourage a 234 sense of belonging. A program in the Netherlands described by Clerkx and Trentelman (2008) provided targeted supports including housing for homeless adults with “learning disabilities” (a term used in the Netherlands that includes both all levels of intellectual delay, as well as specific learning disabilities) in order to improve quality of life through supporting use of specialized services for mental healthcare and housing. There is a need for “plain language” information to be provided for people with very limited reading ability, on topics such as healthcare and personal responsibility, access to healthcare, mental illness, tenants and landlord responsibilities for housing, financial issues, and others. The Psychiatric Patient Advocate Office—Ontario (2003) has provided information on understanding community financial capacity assessment for clients themselves using simple language. SUMMARY AND CONCLUSION There are many challenges to understanding the issues faced by both the adults with multiple challenges (the “dual diagnosis” group) who are homeless, and the services that wish to provide support and care for them. There needs to be, first, accurate identification of those who are intellectually disabled and currently residing in the homeless shelters; second, a high suspicion of and accurate diagnosis and treatment of their mental illnesses; third, an understanding and addressing of the challenges in obtaining and understanding in what way and why this population is both vulnerable and hard-to-serve; and finally, a provision of services that foster personal autonomy and choice within a community, while preventing neglect and abuse. The four mental health principles of clinical care, advocacy, research, and education can guide the development of support that is helpful, client centered, and morally and ethically appropriate. Professionals need to be aware that providing choice and empowerment with appropriate support is qualitatively different from providing superficial choice without support, which can and does result in vulnerable adults becoming even more at risk of abuse and neglect. Clinical care includes services based on the following characteristics: flexibility, meeting the client where he or she lives, consideration of capacity to consent in order to avoid neglect issues, and understanding of the lifelong and pervasive effects of intellectual delay in all facets of life. Effective and directed research is necessary to confirm information that has been clinically identified, and that services offered to this population have the effect that is planned. It will be necessary to address the impression that adults with intellectual delay are not clinically identified. Appropriate advocacy will ensure that the challenges that adults with a triple diagnosis experience do not exclude them from either clinical and social support, or the scientific study of the homeless population. In addition, there is a need for ongoing education of clients, staff, family members, and healthcare professionals. In summary, to help adults with a triple diagnosis to function at their best, benefitting from comprehensive supportive treatment and care based on a solid understanding of their needs and abilities, is an important goal. However it is also important to provide these vulnerable adults with protection from both Journal of Policy and Practice in Intellectual Disabilities Volume 10 Number 3 September 2013 D. C. Lougheed and S. Farrell • The Challenge of a Triple Diagnosis neglect and abuse by individuals and by society. Respecting an individual’s human rights including removing barriers to healthcare, housing, freedom of the person, and protection of the law. To be treated with respect is the foundation of this care. Homelessness should not be an acceptable outcome. REFERENCES Bedard, C., Drummond, C., Ricciardi, J., & Husband, F. (2003). 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Family Therapy for Schizophrenia: Co-Occurring Psychotic and Substance Use Disorders Jennifer D. Gottlieb,1 Kim T. Mueser,1 and Shirley M. Glynn2 1 2 Boston University University of California, Los Angeles, CA People with schizophrenia have a high prevalence of co-occurring substance use disorders, which is related to a worse course of psychiatric illness, more frequent relapses, and increased depression and suicide, compared with those with schizophrenia alone. The Family Intervention for Dual Diagnosis (FIDD) program, which includes psychoeducation and goal setting and focuses on building communication and problem-solving skills within the family, can aid in decreasing the stress related to having a close relationship with someone with a dual disorder. Here, the case of a young man with psychosis and marijuana dependence is examined. This article describes how the FIDD intervention helped him with his problematic substance use, as well as to build skills within his relationship for increased C 2012 Wiley Periodicals, Inc. J. Clin. Psychol: In Session empathy and reduced interpersonal stress.  68:490–501, 2012. Keywords: schizophrenia; psychosis; substance use disorders; serious mental illness; dual disorders; family therapy; behavioral family therapy Schizophrenia is a severe mental illness characterized by psychosis, apathy, social withdrawal, and cognitive impairment. With the development and validation of a growing range of evidencebased treatments for schizophrenia, the previously held notion that the disorder is intractable and untreatable has been debunked. Nevertheless, schizophrenia continues to be one of the most disabling psychiatric disorders, and the World Health Organization has ranked it as 1 of the top 10 leading causes of disability worldwide. People with schizophrenia, as well as other severe mental illnesses (SMI) such as bipolar disorder and treatment-refractory major depression, have a high prevalence of co-occurring substance use disorders (or dual disorders). The rates of lifetime substance abuse of about 50% are much higher than the lifetime prevalence of substance use disorders in the general population (about 15%). Clients with dual disorders have a worse course of psychiatric illness than persons with SMI alone, including more frequent relapses and rehospitalizations, homelessness, poor health, legal problems, and increased depression, hopelessness, and suicide (Drake, O’Neal, & Wallach, 2008). Over the past two decades a growing consensus has emerged that traditional approaches to treating dual disorders, such as having separate clinicians treat each disorder or treating the socalled primary disorder first followed by treating the so-called secondary disorder, are ineffective. To replace these outdated approaches, integrated treatments have been developed that target the treatment of both disorders at the same time, by the same clinician. Most integrated treatment programs have focused on group or individual interventions (Barrowclough et al., 2010), or their combination. Although progress has been made in integrated treatment, the results from controlled studies are inconsistent, and improvements are often modest at best, suggesting a need to improve their effectiveness. This research was supported by Grant No. MH62629 from the National Institute of Mental Health National Institute on Drug Abuse. This paper is subject to the National Institutes of Health Public Access Policy. The authors appreciate the following persons for their contributions to this study: Cori Cather, Lindy Fox, Roberto Zarate, Haiyi Xie, Greg McHugo, Robin E. Clark, Rosemarie Wolfe, and Karen Sullivan. Please address correspondence to: Jennifer Gottlieb, Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Ave. West, Boston, MA 02215; e-mail: jgott@bu.edu  C 2012 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 68(5), 490–501 (2012) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21852 Family Therapy for Schizophrenia 491 One potentially fruitful area may be working with the family. Dual disorders can have deleterious effects on relatives by increasing their burden of care and leading to interpersonal conflict. Family members are more likely to hold a relative with a dual disorder responsible for his or her psychiatric symptoms than relatives with only SMI, and tense and stressful family relationships may contribute to more frequent symptom relapses (Pourmand, Kavanagh, & Vaughan, 2005). This strain can result in the loss of family support, leading to housing instability, homelessness, and a more severe course of both disorders. Family treatment has been repeatedly shown to be effective for SMI (Dixon et al., 2010). Similarly, there is ample documentation of the efficacy of family-based treatment for substance use disorders (Stanton & Shadish, 1997). However, until recently, less attention had been paid to working with families of people with dual disorders. Increasing family coping skills and decreasing the stress of having a close relationship with someone with a dual disorder could enable families to provide critical supports that contribute to improved outcomes. With this in mind, the Family Intervention for Dual Diagnosis (FIDD) program was developed (Mueser, Noordsy, Drake, & Fox, 2012). Described in more detail below, the FIDD program includes psychoeducation and focuses on building communication and problem-solving skills in family members, including the client. In a recent randomized controlled trial (Mueser et al., 2012), the FIDD program was associated with client improvements in psychiatric, substance abuse, and functional outcomes over the 3-year study period, and benefited relatives across a range of outcomes. Clients in FIDD, compared with brief family psychoeducation, had significantly less severe psychiatric symptoms and psychotic symptoms, and there was a trend for them to improve more in overall functioning. Relatives in FIDD acquired more knowledge of dual disorders and mental health functioning than those in psychoeducation alone. Although continued study of FIDD is needed, these findings support the utility of family intervention for dual disorders, as well as the added benefits of communication and problem-solving training. FIDD The FIDD program was adapted from the behavioral family therapy model for severe mental illness (Mueser & Glynn, 1999). FIDD is based on an expanded conceptualization of the stressvulnerability model of SMI and is informed by the stages of change, modified for use with those who have dual disorders. Expanded Stress-Vulnerability Model This model posits that SMI (as well as co-occurring substance use) is caused by a psychobiological vulnerability determined by genetic and other biological factors, and that the course of the disorders (symptoms, relapses, functioning) is influenced by the dynamic interplay among psychobiology, stress (e.g., life events, exposure to high levels of interpersonal conflict), the social environment (e.g., social support), and client coping skills (e.g., social skills, stress management skills). Accordingly, the course of SMI can be improved by reducing biological vulnerability through medications and minimizing substance use, reducing socioenvironmental stress, improving social support, and improving coping skills. The FIDD program was designed to address the goals that follow from the stress-vulnerability model through a combination of three strategies: (a) providing information about dual disorders and their treatment to facilitate medication adherence and the family’s ability to make informed treatment decisions; (b) teaching communication and problem-solving skills to reduce family stress, increase social support, and facilitate the ability of family members to achieve their personal goals; and (c) tailoring those skills to the unique needs of each family. 492 Journal of Clinical Psychology: In Session, May 2012 Stages of Treatment The stages of change model, which proposes that people alter unhealthy behaviors by proceeding through a sequence of distinct motivational states, was adapted for FIDD (Mueser et al., 2003). Four stages are identified, each characterized by a unique pattern of behavior with an explicit goal for that stage. During the engagement stage, the client does not have a therapeutic relationship with the clinician, and the clinician’s goal is to establish such a relationship through regular contacts. During the persuasion stage, a therapeutic relationship has been established but the client continues to abuse substances with no clear desire to reduce; hence, the clinician’s goal is to instill motivation for change, as indicated by reduction in substance use or abstinence. During the active treatment stage, the client has made progress towards reducing substance use or achieving abstinence and the clinician’s goal is to eliminate the client’s harmful use of substances. During the relapse prevention stage, harmful use of substances has been eliminated and the clinician’s goal is to help prevent relapses. Conceptualizing treatment according to the client’s stage of change helps clinicians optimize their therapeutic interventions by ensuring that they are consistent with the client’s motivational stage. Although the term persuasion is used to describe the clinician’s goal when the client has not identified working on substance abuse as a goal, this does not mean the therapist cajoles or prompts the person to change his or her behavior. In contrast to some traditional substance abuse therapies in which the clinician takes an active, directive stance against substance use, in FIDD the clinician adopts a more exploratory, collaborative approach to understanding the client’s experiences, including how substance use may have interfered with important goals or values, to instill motivation for change. If a client comes to treatment with a desire to reduce or stop substance use, then this is adopted as a therapeutic goal. However, if the client does not initially articulate this goal, then the clinician helps the person set and work towards alternative goals, and highlights obstacles to achieving them caused by substance use as they occur over the course of treatment. This process helps clients see the negative effect of substances in their lives, leading many to choose to address the issue directly. The stages of treatment model are also used to inform the organization and pacing of the FIDD program. Sessions focus initially on establishing a therapeutic relationship with the family, followed by providing information (and other motivational enhancement strategies, as needed) to motivate them to work on the client’s substance abuse. When there is evidence of sufficient motivation, attention shifts to further reduction and abstinence, followed by helping the family develop relapse prevention strategies when harmful use has ceased. Family Sessions Family sessions include the client and any involved family members. Sessions last for about an hour, are conducted at a location convenient for the family (e.g., home or clinic), and are usually provided on a declining contact basis (e.g., weekly, biweekly, monthly) for 9 to 18 months. FIDD is organized into a series of phases: engagement and assessment, psychoeducation, goal-setting, communication skills training, problem-solving training, and relapseprevention/termination. Communication and problem-solving training are conducted using social learning methods such as role-plays, in-session practice, and regular out-of-session practice assignments, typically scheduled during ongoing weekly home family meetings. These treatment components are discussed in more detail in the case example below. The number of sessions spent on each phase is flexible, with all aspects of the program individualized to address the unique needs of each family. Table 1. Case Illustration Presenting Problem and Client Description We present here the case of “Robert,” who participated in the FIDD program for approximately 1.5 years with his girlfriend, “Jessica.” Robert was a 33-year-old unmarried African-American man with a diagnosis of schizophrenia, paranoid type, who was referred to the FIDD program Family Therapy for Schizophrenia 493 Table 1 Phases of FIDD, Corresponding Client Stages of Substance Abuse Treatment, and Number of Sessions Phase of FIDD 1. Engagement/assessment 2. Psychoeducation/goal-setting 3. Communication skills training 4. Problem solving training 5. Relapse prevention/termination Client stage of treatment No. of sessions Engagement or persuasion Persuasion or active treatment Persuasion, active treatment, or relapse prevention Persuasion, active treatment, or relapse prevention Active treatment or relapse prevention 1-3 4-8 4-8 5-15 1-3 Note. FIDD = Family Intervention for Dual Diagnosis. by his psychiatrist. Robert, who had recently started pharmacological treatment at a specialty psychosis program in a major metropolitan area, eventually disclosed (at the urging of his girlfriend) that he had a history of alcohol abuse and was using marijuana daily. His initial complaints also included low motivation, depression, boredom, distractibility, sleep difficulties, and beliefs that his coworkers were trying to poison him at the factory where he worked. Robert came from a large, somewhat neglectful family with a history of substance use, mood disturbance, and psychosis. Robert’s parents were divorced and he described his relationship with his father as distant. From a previous relationship, Robert had one young daughter with whom he had frequent contact. He was currently in a 3-year relationship with Jessica, who held a full-time job that involved long hours and early morning shift work. Soon after they began dating they moved in together, because Robert lacked money and was in danger of becoming homeless. Robert had experienced multiple problems for several years, including difficulty maintaining employment due to the combined effects of substance use and psychotic symptoms, bouts of homelessness, and financial problems supporting himself and providing support for his daughter, whose mother had full custody. As a result, Jessica supported them almost entirely, including paying rent, buying food, and also giving Robert weekly spending money. Robert’s psychotic symptoms and paranoia also made it difficult for him to develop and maintain friendships, and so he had little social contact apart from outings with Jessica and family get-togethers. At the outset of treatment, Robert’s daily activities included sleeping for several hours after Jessica had left for work, smoking marijuana, looking for permanent work, playing video games, and going to his temporary job in the evening for his 3-hour shift. Despite Robert’s social avoidance, he was affable and friendly in psychotherapy, and demonstrated a good sense of humor in his interactions with Jessica. Although Jessica often expressed frustration with “having to do everything around here,” she tended to become emotionally withdrawn when upset with Robert. She often channeled her distress into increased cigarette smoking and unhealthy eating, and frequently went out with her girlfriends to “blow off steam,” which often involved binge drinking. In the initial sessions, Jessica was sometimes affable like Robert, but at other times became affectively flat and withdrawn, particularly when she was upset with Robert. Case Formulation A close examination of Robert’s problems, including his low motivation for productive activity, and his substance use, paranoia, and social isolation, suggested that they stemmed from several sources. Given his family history of substance abuse and psychiatric problems, his biological vulnerability to developing a substance use disorder or a psychiatric condition was quite high. These vulnerabilities may have been fueled by the stress of a chaotic upbringing. Robert reported that he had not received much positive attention as a child and adolescent, in part because of his large family, his parents’ marital discord, and their own psychiatric problems. Robert had become socially withdrawn and apathetic about pursuing further education and a career, despite 494 Journal of Clinical Psychology: In Session, May 2012 some interest in becoming a woodworker. In addition, the neighborhood in which Robert grew up was impoverished and prone to street violence and he felt that he was “always watching [his] back” during his adolescent years, a degree of hypervigilance that may have contributed to some of his paranoid ideation. Further contributing to the development of psychotic symptoms was Robert’s substance use. In his early 20s, Robert spent a lot of time in bars and drinking with friends. His drinking became problematic around his mid-20s. When his family grew concerned, he decided to quit. At the beginning of FIDD, Robert reported that he had not used alcohol for approximately 5 years. However, after he stopped drinking, he began to smoke marijuana on a more frequent basis so he would have something to do when friends were drinking around him. He then began to use marijuana on his own as well, to wake up in the morning and to reduce his anxiety throughout the day. Robert admitted that although he smoked marijuana to relax, he often ended up feeling more paranoid, thus creating a vicious cycle whereby the marijuana exacerbated his vulnerability to psychosis and associated anxiety. Robert’s drug use and paranoia interfered with his ability to hold a job, which affected many other areas of functioning, including his relationship with Jessica and his financial situation, which therefore affected his relationship with his daughter. Although clearly bright with a sharp wit, Robert did not have a high school diploma and was unable to find meaningful or interesting work that paid well. As a result, he often was only eligible for temporary unskilled work, which meant a sporadic schedule and the graveyard shift with unfamiliar people, all of which worsened his psychiatric symptoms. In addition, because he was often bored at work, he smoked marijuana before going to work, which decreased his job performance and increased his paranoia, resulting in avoidance of coworkers and managers and sometimes calling in sick on days when his paranoia was acute. Jessica, although clearly very much in love with Robert and fairly tolerant of many of his problems, was at her wit’s end with some of his behaviors and was desperate to get help. She reported feeling confused by his paranoid beliefs and was unsure about how to respond to them. However, Jessica also played an indirect role in maintaining his problem behaviors. Although she often became angry about Robert’s spending money on marijuana and at his odd beliefs and behaviors, she supplied him with money on a weekly basis to spend on “necessities, like his lunch, and stuff for the house,” which, in turn, he often spent on marijuana instead. Despite working full-time, Jessica took on the majority of the household tasks and paying bills. She reported feeling anger about Robert’s lack of contribution to the household, and often took on tasks herself once it became apparent that he was not going to complete them, further increasing tension in their relationship. She frequently threatened to “kick him out if he doesn’t change,” but had never followed through on her threats. Jessica’s tendency to adopt a caregiving role with Robert appeared to perpetuate some of his reluctance to seek more stable employment and to contribute more to the household. Course of Treatment Both Robert and Jessica were initially reluctant to participate in FIDD because they had no past experience with individual or family therapy and were uncomfortable with the intrusive nature of therapy as they conceived of it. However, once they learned more about FIDD, particularly its emphasis on education and skill building, they became interested. They agreed to participate to address Robert’s substance abuse and to learn more about his psychiatric disorder and how to deal with it. Before education and improving communication and problem-solving skills can commence in FIDD, the clinician may need to evaluate the couple’s commitment to their partnership and address any uncertainty or disparity about the commitment, as well as endeavor to increase positive experiences in the relationship. Despite Jessica’s upset at Robert’s substance use and her threats to leave him, both of them wanted to make their relationship work, which was a primary motivation for participating in FIDD. Throughout the course of FIDD the therapist looked for opportunities to draw attention to positive aspects of the couple’s relationship, to bolster engagement in mutually rewarding activities, and to establish positive expectation for mutually Family Therapy for Schizophrenia 495 desired changes. For example, the clinician prompted the couple to make an inventory of their partner’s strengths, which were periodically reviewed. At the end of particularly challenging sessions, each member was asked to describe one thing that occurred during the week for which they were grateful to their partner. These strategies helped strengthen the couple’s resilience and keep them engaged in both the relationship and the FIDD program. Engagement and psychoeducation. The initial sessions involved building rapport with the couple and gathering information to develop a case conceptualization and a treatment plan. A good deal of time was spent understanding Robert’s substance use habits, triggers, and perceived benefits to assess both his stage of change as well as Jessica’s willingness to make changes. Although Robert acknowledged that he wanted to do more with his life, and that it was hard when Jessica became upset with him, he did not think that his marijuana use was problematic. Although this revelation upset Jessica, the clinician responded to his perspective in a nonjudgmental way, and Robert was asked if he would be willing to revisit these beliefs and experiences at a later point in the program, to which he agreed. Following engagement, several weeks were spent on psychoeducation. Robert and Jessica initially took a light approach to the handouts and worksheets, which involved a lot of joking, suggesting that they were uncomfortable discussing some of the topics, such as the nature of psychotic symptoms, and the effect of substance use on work and intimate relationships. Upon further discussion, Jessica admitted that they had never openly talked about any of these topics and that she often pretended that the psychotic symptoms were not as prominent as they actually were. Once their avoidance and reluctance were normalized, the couple began to delve into the educational materials more conscientiously, and many serious and fruitful discussions ensued. Although Robert felt validated after learning that other people had the same experiences as he had, he initially seemed embarrassed about his psychotic symptoms, often asking, “Am I nuts?” Jessica showed a newfound empathy for Robert based on these discussions. The educational sessions, particularly the stress-vulnerability model and the discussion of how biological vulnerability can make people more sensitive to the effects of substances, helped the couple. This increased understanding of the relationship between psychosis and substance use opened a door for Robert by providing new insight into his difficulties, and increased his motivation to re-consider his drug use. Goal setting and treatment planning. The next phase of FIDD involved helping Robert to develop treatment goals and encouraging Jessica to establish personal goals as well. Having relatives or significant others work towards personal goals in FIDD, in addition to the client himself/herself, can both improve their well-being and serve as a positive role model to the client. Robert’s treatment goals were as follows: (a) to look into my GED and take the test; (b) to look into trade schools; (c) to have more structure to my day; (d) to think more about my pot use; and (e) to get along with Jessica better. Jessica, although initially reluctant to set her own goals, decided to work on looking into smoking cessation programs and starting to exercise and lose weight. Communication training. An often crucial component of FIDD is communication training and practice. Many families struggle with effective communication, which can become more pronounced with a relative with a dual disorder. Clients may become withdrawn, anxious, and ashamed and their negative symptoms/depression may reduce their desire and ability to interact meaningfully. Family often become unsure about what to say to their relatives about their symptoms and may feel resentful or critical about functional difficulties or ongoing substance use. Communication training in FIDD is based on social skills training methods. These methods include establishing the rationale for a specific skill, breaking the skill down into component steps, modeling the skill, engaging family members in practicing the skill in role-plays, providing positive and corrective feedback followed by additional practice, and collaboratively developing home assignments for family members to practice the skill on their own. Some of the skills 496 Journal of Clinical Psychology: In Session, May 2012 taught in FIDD include expressing positive feelings, making a request, and expressing negative feelings. Although Robert and Jessica initially scoffed at the idea of role-playing communication skills, they both readily admitted that they had difficulty communicating about sensitive topics and that they had tended to avoid these discussions altogether, such as talking about Robert’s symptoms or marijuana use. Instead, they tended to use humor to deflect their uncomfortable feelings when communicating, or they argued and yelled at each other. As a result, approximately 10 sessions were spent on communication training. The initial in-session training involved having the couple use these specific skills to work on less emotionally charged topics, such as the division of household chores and TV-watching schedules. For example: Therapist Robert Jessica Therapist : : : : Robert : Therapist : Robert : Jessica : How about we try a role-play to practice this “Making a Request” skill? (laughs) Yeah, I don’t think so. I’m no actor really. Right, that’s not really our thing. We know how to do it; we don’t need to. I completely understand your reluctance, and I do know that you two have a lot of good skills under your belt as a couple. I also know that some things have been tough, and this is really common for couples going through the kinds of things that you are going through. I wonder if we might just give it a try, just to see if this new way helps, even a little bit. I don’t know, I feel stupid. I know it feels uncomfortable initially. When I first started doing role-plays in front of people, I felt a little funny too. That’s totally normal. But it can make a big difference to try things out here first; that way when a conflict comes up in real life, you’ll feel more relaxed about it and know how to handle it. How about I play you, Robert, first? Beforehand, I can suggest some things for Jessica to say. That way everyone might feel a little more prepared. Then we can switch off later, if we want to. What do you think? Okay, I can see how you do it. Make sure you talk in a deep voice though (laughs). Yeah, that sounds easier than both of us trying to do this together right now. As the couple became more skillful at communicating, more challenging topics were initiated, such as Jessica’s telling Robert, “When you are high when I come home from work, it makes me feel sad about our relationship” and “I would appreciate it if you didn’t make a joke when I mention something that upsets me and I want to talk with you about it.” Gradually over time, at the beginning of sessions, Robert and Jessica began to bring up difficult arguments that they had during the week, and requested to role-play their communication in session. They began to integrate improved communication into their lives and found that these skills helped them talk about and solve problems, both as individuals and as a couple. Problem-solving strategies. Clients with dual disorders often have difficulty knowing how to approach and solve daily problems, which can lead to continued avoidance of these problems, increased substance use as a coping strategy, and eventually an exacerbation of the original problem. As a result, a substantial part of FIDD is devoted to teaching practical, stepby-step problem-solving skills that can be done together by the family, or by the individual client with the help of relatives. Initially, the clinician teaches the steps of problem solving to the family, demonstrating each step by leading them through an example. As the family learns the skill, the clinician shifts the responsibility for problem solving to the family, while continuing to provide prompting, coaching, and feedback. The time spent in sessions focused on practicing problemsolving steps, with home assignments developed to practice the skills outside of sessions. Robert had a relatively long problem/goal list, which had become a source of frustration to both him and Jessica after years of little progress. The steps of problem solving were first introduced in session while working on a nonemotionally charged problem: Robert’s not knowing where to look into getting his GED. As Robert and Jessica became more adept at problem solving, more challenging problems were addressed, such as Robert’s lack of daily structure. Family Therapy for Schizophrenia 497 The therapist had to occasionally encourage Robert to stick to the steps of problem solving, so that he did not become frustrated and give up in the middle of the process. For example, creating increased daily structure was a big challenge for Robert and involved multiple steps (buying his own alarm clock, finding out the cost of a gym membership, carving out a time for chores and GED preparation), many of which necessitated overcoming obstacles (e.g., turning off the alarm when it beeped after Jessica left for work, getting drawn into several hours of playing video games, having his daughter’s mother cancel their visit) and developing methods for rewarding himself for progress towards his goal (e.g., playing 30 minutes of video games for every hour of GED study). During this problem-solving training component, although Robert initially had articulated working on marijuana use as a treatment goal, he remained ambivalent about cutting down. Robert was in the persuasion stage of treatment, so the family work focused on increasing motivation through the use of motivational interviewing techniques. For example, a payoff matrix was used in session to help Robert explore the pros and cons of continuing to use marijuana versus cutting down or stopping. Robert tended to withdraw and not show up for FIDD sessions when he felt pressured, and so session time was a balance between working on his other treatment goals (such as improved daily structure and increased fun activities for the couple) and motivational enhancement strategies. To keep Robert engaged in FIDD, the clinician also conveyed empathy about his ambivalence about his drug use and normalized his experience of finding some beneficial effects of marijuana on anxiety and psychotic symptoms. The clinician’s validation, normalization, and nonjudgmental stance appeared to increase Robert’s willingness to stick with the FIDD program and to discuss his thoughts and feelings about his drug use. Approximately 4 months into the FIDD program, Robert reported a frightening experience with marijuana while Jessica was at work. He had smoked a larger amount than was usual for him and suffered severe paranoia and a panic attack involving the belief that he was about to die. As a result, he went to the emergency room, where he was examined and released. After that event, and the clinician’s explanation that marijuana use can sometimes cause panic attacks, Robert decided that he was ready to start reducing his marijuana use and that he wanted to stop altogether. Problem-solving work focused on Robert’s developing strategies to deal with cravings, boredom, and triggers (playing video games, loneliness, etc.). Figure 1 presents one of Robert’s problem-solving exercises. Robert began to reduce his marijuana use, and as he began the action stage of treatment, it also became possible to address Jessica’s indirect role in reinforcing his use and his lack of contribution to the household. The couple decided how to modify their daily activities and time spent together without contributing to Robert’s substance dependence. For example, they were uncertain how Robert would assume household responsibilities (i.e., grocery shopping) without spending the money on marijuana instead. The couple developed a creative set of solutions that involved purchasing grocery store gift certificates for Robert to use each week. In addition, a variety of related strategies were developed: (a) Robert would call Jessica right after he spent money on something healthy and worthwhile so she could praise him and thank him and (b) a reward for the couple was planned (e.g., going to the movies) if a week went by without Robert’s spending extra money on drugs. These exercises built a robust skill foundation for the couple, which allowed them to move toward their individual and shared goals. Robert’s marijuana use decreased in frequency and quantity. Feeling under less pressure, Jessica began a weekly exercise regimen, and accepted a referral for a local quit smoking program. Robert used his communication skills as the problem solving progressed, particularly on this drug abuse. As Robert began marijuana abstinence, he learned about his personal cues and triggers and identified cigarette smoke as a trigger for craving. Jessica, who was a heavy smoker and had initially expressed interest in quitting but had not moved into the action stage yet, frequently smoked at home and when they were out together. Robert finally chose to tell her in session, “It is really hard for me when you smoke in front of me. It is a trigger for me for pot. I know you want to help me quit, but it makes it worse when you smoke. I’d appreciate it if you would work on quitting smoking for my sake, or at least not smoke when I am around.” This interaction went well and, as a result, Jessica changed her behavior and followed up on the quit 498 Journal of Clinical Psychology: In Session, May 2012 Figure 1. FIDD problem-solving worksheet completed by Robert in session smoking program referral. Robert also used his improved communication skills (e.g., refusal skills) with coworkers who invited him to smoke marijuana during their shift breaks, and also with his manager to ask him for more stable shift hours. The integration of communication skills and problem-solving skills allowed Robert to make greater progress on his goal of marijuana abstinence. Relapse prevention planning and treatment termination. Approximately 1 year and 25 sessions through the FIDD program, Robert had made substantial progress toward many of his goals. He had first reduced his frequency of marijuana use and then stopped using completely and maintained his abstinence even in difficult situations, such as when coworkers invited him to use while he was bored at work. He also completed the paperwork for the GED test registration and started studying for the test. Although he still had some paranoid beliefs, he managed them Family Therapy for Schizophrenia 499 better without the exacerbating effects of the marijuana. In addition, he and Jessica reported that they were arguing less, talking more, and having more fun together. Given these improvements, relapse prevention plans for both psychosis and substance use were developed over the course of several sessions. These written plans were a collaborative effort among the clinician, Robert, and Jessica, and included several components: a list of warning signs of impending psychosis, triggers to use marijuana, effective coping strategies, and actions for Robert and Jessica to follow should a marijuana lapse occur or a symptom increase. In addition, protective factors that kept Robert healthy were also highlighted. These included maintaining psychiatry appointments, not running out of medications or missing doses, keeping up with daily structure, using drug refusal skills, and communicating honestly with Jessica when his symptoms were bothering him. Once the relapse prevention plans were developed and approved by the couple, the session frequency decreased from weekly to every other week. Robert and Jessica continued to practice problem solving as a homework assignment. As a result, the final sessions were spent planning to help them continue to use the problem-solving and communication skills learned throughout FIDD, now that treatment was coming to a close. Outcome and Prognosis Robert and Jessica completed the FIDD program in approximately 18 months and 32 sessions. By the end of treatment, many new behaviors had been implemented. Robert had moved from expressing no desire to stop marijuana use to a 3-month period of abstinence, and he reported reduced paranoia and depression and increased energy. He had learned how to deal with cravings and noted a reduction in them as well. Robert had also signed up for the GED and had been given a test date. His studying was sporadic, but he continued to use the study guides. Although Robert was anxious about the upcoming test, he was proud of taking steps toward his goal. He also increased his work hours and was more assertive with his managers about scheduling. Robert and Jessica reported that his parenting skills had improved. His daughter’s mother was supportive of his recovery and became more willing to allow Robert and his child to spend time together. Robert noted that when he visited with his daughter, he felt more motivated to plan and follow through with fun, child-friendly activities, rather than staying home and watching TV together. The couple reported that their relationship had improved as well and included more meaningful time together, less tension and arguing, and less avoidance of talking about upsetting feelings. Jessica reported that she was no longer thinking of ending their relationship and the couple had made an overt decision to stay together and even began to contemplate marriage. Both Robert and Jessica had learned much more about schizophrenia, substance use and its consequences, and dual disorders, which increased their motivation to work on other problems and created a shared empathy. Despite these positive outcomes, there were some challenges with this case. Although Robert had stopped using alcohol prior to FIDD, toward the end of treatment he began drinking socially again. This behavior change was attributed to his reduction in paranoia and social isolation and his increased camaraderie with coworkers, who now invited him to join them for drinks after work. Given Robert’s history of alcohol abuse and newfound abstinence from marijuana, even this social drinking was of concern to the clinician and Jessica. However, Robert perceived the social benefits of drinking as outweighing the risks. Further, because Jessica also drank on a regular basis with her girlfriends and was unwilling to change this behavior, there was little deterrent for him to avoid alcohol completely. As a result, time was spent in the final FIDD sessions on how to monitor Robert’s social drinking and develop a plan for responding to any increases in drinking. Jessica did not progress on her personal goals in FIDD (i.e., smoking cessation, exercise, weight loss), although she had enlisted a friend to join her for occasional walks. Toward the end of FIDD, Jessica decided to begin individual psychotherapy at another mental health clinic to address upsetting experiences from her childhood. The clinician reinforced this positive step. One hope was that her behavior would also highlight the benefits of therapy for Robert, who had 500 Journal of Clinical Psychology: In Session, May 2012 declined a referral for therapy to address distress he still experienced related to his symptoms. By the end of FIDD, Robert had still not elected to follow through on a referral, but had agreed to continue to see his psychiatrist on a consistent basis and take antipsychotic medications. Given his history of treatment nonadherence, the fact that he completed 18 months of FIDD with full medication adherence and agreed to ongoing contact with a psychiatrist was an important achievement. Clinical Practices and Summary This case highlights the multitude of difficulties that schizophrenia can cause: the functional debilitation for the individual with the disorder; the stress experienced by the partner in understanding, empathizing, and coping effectively with the consequences of the disorder; and the strain on the relationship as a whole. The addition of a substance use disorder, particularly when left unaddressed by the couple over a long period, puts further strain on the relationship. Directly addressing substance abuse was particularly helpful in this case, because both Robert and Jessica had been minimizing its consequences and effects on their relationship. As minimization or avoidance of addressing substance use in families is a common problem, this case emphasizes the benefits of drawing out the problematic drug and alcohol use as the family becomes ready to address it. In addition to the positive outcomes that accrued as a result of the FIDD program, this case also highlights the challenges of effectively treating dual disorders— within the individual, the family, and particularly a couple. There were at least three lessons learned with this couple that apply to working with this population as a whole. First, the lessons of the chronic and relapsing nature of dual disorders. Robert made significant reductions in his marijuana use but his resumption of drinking was a risk for relapse. This case illustrates the need to maintain close monitoring of the client’s functioning and provide booster sessions and family meetings to address continued addiction. Second, the case demonstrates the need to instill and cultivate motivation to address substance abuse. It is difficult to motivate clients to change substance abuse when the negative consequences of their use are not apparent or are compensated for by someone else. Talking openly about Robert’s marijuana use and helping Jessica to express her resentment towards Robert for “not pulling his weight” around the house enabled the couple to overcome their minimization of Robert’s drug use, eventually leading to cessation. Teaching effective communication and problem-solving skills facilitates the family’s ability to talk honestly while maintaining a low-stress environment to avoid triggering relapses. Third, the case illustrates the role of goal setting in addressing substance abuse. In session, motivational interviewing methods such as identifying the client’s personal values and helping him see the discrepancy between those values and his substance abuse, were used to move the client toward reducing his drug use. For instance, Robert wanted to be a better father to his daughter and wanted to improve his relationship with Jessica. Articulating these goals and exploring how Robert’s marijuana use interfered with them were central to Robert’s developing motivation to get control over his substance use and eventually his choice to become abstinent. Research has demonstrated that the comorbidity of schizophrenia and substance abuse causes a host of problems for clients in terms of heightened psychotic symptoms, increased difficulty with daily functioning, and relationship dysfunction. The FIDD program can help clients and their relatives to become more effective in coping with stressors that exacerbate both disorders, as well as to reduce substance use and improve their relationships. Selected References and Recommended Readings Barrowclough, C., Haddock, G., Wykes, W., Beardmore, R., Conrod, P., Craig, T., . . . Tarrier, N. (2010). Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: Randomised controlled trial. British Medical Journal, 341. doi:10.1136/bmj.c6325 Dixon, L.B., Dickerson, F., Bellack, A.S., Bennett, M.E., Dickinson, D., Goldberg, R.W., . . . Kreyenbuhl, J. (2010). The 2009 PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin, 36, 48–70. doi:10.1093/schbul/sbp115 Family Therapy for Schizophrenia 501 Drake, R.E., O’Neal, E., & Wallach, M.A. (2008). A systematic review of psychosocial interventions for people with co-occurring severe mental and substance use disorders. Journal of Substance Abuse Treatment, 34, 123–138. doi:10.0101/j.jsat.2007.01.011 Mueser, K.T., & Glynn, S.M. (1999). Behavioral family therapy for psychiatric disorders (2nd ed.). Oakland, CA: New Harbinger. Mueser, K.T., Glynn, S.M., Cather, C., Xie, H., Zarate, R., Smith, M.F., . . . Feldman, J. (2012). A randomized controlled trial of family intervention for co-occurring substance use and severe psychiatric disorders. Manuscript submitted for publication. Mueser, K.T., Noordsy, D.L., Drake, R.E., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York, NY: Guilford Press. Pourmand, D., Kavanagh, D.J., & Vaughan, K. (2005). Expressed emotion as predictor of relapse in patients with comorbid psychosis and substance use disorder. Australian and New Zealand Journal of Psychiatry, 39, 473–478. doi:10.1080/j.1440-1614.2005.01606.x Stanton, M.D., & Shadish, W.R. (1997). Outcome, attrition, and family-couples treatment for drug abuse: A meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 122, 170–191. doi:10.1037/0033-2909.122.2.170 Copyright of Journal of Clinical Psychology is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

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