Research Needed for Those with IDD/MI Dual Diagnosis!!!!

We need more research in the following areas to advance the treatment of those with IDD/MI dual diagnosis.

1. The best methods of restraint and seclusion 

2. The best methods for de-escalating a crisis before, during, and after the crisis 

3. How to introduce body cameras to the psychiatric system 

4. What exactly is trauma-informed care, and examples of trauma-informed care

5. The effectiveness of barcode medication equipment to protect service recipients from medication errors

6. How ID cards or wristbands resolve major safety concerns, and how to encourage service recipients to wear their ID cards or wristbands 

7. How statewide bed registries and trackers reduce the amount of time a service recipient spends in crisis centers 

8. How many dual diagnosis inpatient beds are needed, and what do hospitals need to do to establish dual diagnostic capability 

9. How to circumvent the Medicaid IMD exclusion and why we need to do so

10. What medical clearance protocols are followed, and how can we ensure compliance 

11. Civil commitment, involuntary medication, forensic commitment, and guardianship standards around the world and country 

12. Ideal coercion-free healthcare for mentally ill service recipients, including the Trieste, Italy model

13. The benefits of having a separate State Hospital for those with dual diagnosis (I.e., a neuropsychiatric center) 

14. Forensic care of those with dual diagnosis and violent criminal charges, and what treatment models are effective for this subpopulation

15. Alternatives to group homes and supportive apartments (I.e., intentional community)

16. The PASRR (Pre-Admission Screening and Resident Review) process and nursing homes for those with dual diagnosis, and why we need specialized units in nursing homes for those with dual diagnosis 

17. The effectiveness of boot camp military-style programs for adults and youth with emotional behavioral disabilities and Autism 

18. How aversive behavioral interventions are abused, such as aversive shock for severe self-harm and aggression

19. How unfairly played group games impact recovery and treatment retention, if at all

20. Why does mechanical restraint go down when chemical restraint goes up 

Fairness During Group Games Treatment Facilities

 Fairness 

When playing group games in mental health and developmental disabilities treatment programs, the games are often improper or unfair. 

This is not as big an issue at the State Hospitals for adults, but it is more of an issue at day programs and private short-term care hospitals for adults. For children and adolescents, fairness is a vicious problem across the continuum of care.  

First off, staff should never be allowed to compete against or alongside service recipients, and staff vs. service recipient tournaments should be prohibited. It can be a safety issue when playing physical games, such as kickball, as a bad kick or throw from staff could cause injury to the service recipient. When staff participate in cognitive games, it can imbalance the ability level of each team due to cognitive deficits as a result of developmental disorders, mental illness, or the medications used to treat them.  

Staff should give everyone an equal opportunity to win. For instance, staff should not help one service recipient find a number on a bingo board and not provide the same assistance to others who ask for it. 

Teams should be divided equally by the number of players and ability levels, and never based on clinical criteria such as commitment status, diagnosis, or level of functioning. When this happens, it perpetuates stigma throughout the system of care that individuals with more severe diagnoses are not capable of winning a game, especially when medication impacts their participation. 

It is fitting that unfair games can contribute to resentment and deep-seated anger towards the entire field of psychiatry, which can cause other problems, such as high restraint and seclusion rates (for children, adolescents, and adults) and low treatment retention rates (especially for adults), among many problems that could potentially result from these feelings. 

First off, we need to assess the root cause of the problems associated with fairness. Then we have to fool around with solutions that might resolve the problems. After that, we need to create regulations that support those solutions.  

The State and the federal government need to design financial incentives for having fair games in treatment facilities. We need to research how unfair games impact the treatment of different types of service recipients.  A lot of service recipients will not make complaints about this because they think it is “too trivial” a complaint. Service recipients should have the right to fair games. It is just not therapeutic to have unfair games in the mental health and developmental disabilities treatment programs.

Please take a moment to comment to let me know what you were here and what you thought of my blog. 

Continuing Care Residential Facility

 I believe we need a non-institutional residential facility designed similarly to a continuing care retirement community with various levels of care that individuals may move through as their needs change; yet, continue to remain with the same treatment team, recommendations, diagnostic assessment, and a familiar environment for those with Autism and/or mental illness and challenging behavior. This type of facility should be run by a nonprofit provider agency or hospital network, not the State, to prevent it from becoming an “institution”. 

Levels of care at this type of facility should include: 

• Forensic Care Units: designed similarly to a therapeutic correctional facility for those with criminal charges
• Intensive Care Units: designed similarly to a forensic facility but with more of a focus on rapid tranquilization using antipsychotic medications and behavior modification, for those with extremely chronic, dangerous behaviors and who fail or get "kicked out" of less restrictive programs
• Inpatient and/or Dormitory Units: service recipients live in a large building with locked and unlocked units 
• Campus Residences: individuals live on a large piece of land in cottages or small dormitories 
• Supervised Apartments: service recipients live in individual apartments with 24-hour staff in a large disability-only apartment complex

This type of facility will increase continuity of care, as the same treatment providers will possibly follow service recipients throughout their time at the facility. It is intended for long-term, lifelong placement, and the individual will receive "Active Treatment." It should not be restricted to those with an IQ under 70, and higher-functioning and lower-functioning service recipients will be admitted to different sections of the facility to allow for appropriate treatment. 

Funding streams may come from the State developmental disabilities agency (possibly as an Intermediate Care Facility for Intellectual Disabilities [ICF/ID]), mental health agency (possibly through its own funds as Medicaid will not fund a psychiatric facility larger than 16 beds), Medicaid (possibly as an Intermediate Care Facility for Intellectual Disabilities [ICF/ID] or Skilled Nursing Facility [SNF]), and more. 

This will be ideal for those who do not succeed in group homes because of their behavior. However, we do not want to make this a prerequisite for admission to a continuing care facility like this. We do not want to wait until someone fails before considering them for a facility like this. 

When the individual receives treatment aimed at reducing challenging behaviors, their challenging behaviors may decrease, and they may move to a lower level of care within the facility. Yet, when there is a crisis or escalation of challenging behavior, they can easily move to a higher level of care without going to the hospital and without police intervention. 

This type of facility will also be ideal for those with primary mental illness (standalone or with a developmental disability) who are discharge resistant or who face significant barriers to discharge due to chronic higher-acuity behaviors, as an alternative to a State institution. Oftentimes, psychiatric hospitals and units only stabilize medications (not provide behavior modification). They only provide acute care, and these individuals have chronic behavioral problems. A facility like this could help supplement the care given in a psychiatric hospital or unit when a State Hospital is not appropriate, including for forensic service recipients. It is widely known that short-term psychiatric hospitalization only causes more disruptions in the lives of those with Autism or severe mental health challenges, and it is also known that short-term psychiatric hospitalization may reinforce the challenging behaviors that led to it. As of yet, there are no better alternatives. 

This type of continuing care facility is an alternative to resolve all these problems.

Autism Therapies

 Other Autism Therapies

There is a plethora of therapies and treatment models available for those with Autism Spectrum Disorder, other than Applied Behavior Analysis (ABA) and Positive behavioral support (PBS), to be used in conjunction with and separate from ABA and PBS, which are just as effective or more effective than ABA and PBS.

Treatments include:

1. the Alert program (the How's my Engine Running program)
2. the Zones of Regulation and Social Thinking curriculum
3. Son-Rise program
4. Animal Assisted Psychotherapy or Pet Therapy
5. Equine Assisted Psychotherapy and Therapeutic Horseback Riding
6. Social Stories
7. Comic Strip Conversations
8. SELF (Safety, Emotions, Loss, and Future) model
9. WRAP (Wellness Recovery Action Plan)
10. Dialectical Behavior Therapy for Special Populations (DBT-SP)
11. The Emotion Regulation Skills System for Cognitively Challenged Clients
12. ESCAPE-Now curriculum
13. Circles program
14. Collaborative Problem Solving model
15. Motivational Interviewing
16. Supportive Humanistic Psychotherapy
17. Trauma Informed Care
18. Cognitive Behavior Therapy (CBT)
19. Trauma-Focused Cognitive Behavior Therapy (TF-CBT)
20. Exposure Response Prevention (E/RP)
21. Psychopharmacological Intervention
22. The TEACCH approach 

Again, we need to not only provide but also promote other therapies in addition to ABA and PBS. Everyone is unique and ABA and PBS do not work for all individuals with Autism. It is not a one-size-fits-all situation. 

Neurobehavioral Programming

Just posting this information about what a neurobehavioral milieu looks like in practice. This contains info from my experience at the Meridell Achievement Center (several years ago) and info from the Internet. Meridell offers two types of programming: traditional behavioral and neurobehavioral. This describes the qualities of a neurobehavioral program for higher-functioning individuals without an intellectual disability (Full-Scale IQ over 70). 

• Assessments should be conducted at admission to determine appropriate strategies and goals, including medication selections. 

• The assessment process should start with a neurophysiological examination, involving a Quantitative EEG with Evoked Potential (QEEG) or Cognitrace Study, reviewed by a Neurologist in consultation with a Neuropsychiatrist / Neuropsychopharmacologist, to determine the presence of a neurological-based psychiatric disorder. The Cognitrace Study, or Complex EEG with Auditory and Visual Evoked Potentials, is a non-invasive (no needles), brain imaging examination interpreted by a Neurologist trained in neurobehavioral disorders especially those related to aggression. 

• Positive findings will allow for precise medication selection which can offer more immediate relief of impulsive, explosive aggression. 

• Testing typically takes about one hour. 

• A Neuropsychiatrist will recommend medications to treat the affected brain areas and stabilize behavior based on the Neurologist’s report. 

• When the individual is stabilized on medication, there should be neuropsychological testing, including tests for IQ, Memory, Executive Functioning, Language, Motor, Achievement, Psychological Testing, and Diagnostic Interview. 

• There should be projective psychological testing to determine symptoms of psychiatric illness and type of personality. 

• There should be Neuropsychiatrists, Clinicians (LCSW, LPC, etc.), Program Staff, Discharge Planners, Neuropsychologists and Neurologists, on the treatment team. 

• There should be suites for QEEG testing and neurophysiological evaluation in the medical areas for higher-functioning individuals. 

• Intensive programming is provided each day, including psychoeducational groups, skills groups, processing groups, recreational therapy groups, and additional recreational, therapeutic activities. 

• Therapy interventions are evidenced-based and informed by models including Cognitive Behavioral Therapy, Systemic Family Therapy, Collaborative Problem Solving, Dialectical Behavioral Therapy, EMDR, and other trauma and relational models. Individual and family therapy is offered every week.

• Therapy includes individual therapy, goals groups, feelings groups, reflection groups, issues groups, psychoeducational Social Thinking and Zones of Regulation groups, recreation therapy, etc.

• There is a drastic difference between a traditional behavioral and neurobehavioral milieu for this population, as described below:

  Neurobehavioral	Behavioral
  Redirecting (without confrontation) Behavioral Contracts (motivate) Modeled behavior by staff Positive Reinforcement Watch for lack of capability Watch for impulsive action The patient receives guided direction The patient was given responsibility/small steps More individual instruction A soothing, less stimulating environment Slower pace Structured transitions (with prompts)	Confronting (empathetic guidance) Interpreting (uncovering insights) Positive peer culture Logical and natural consequences Watch for manipulation (staff splitting) Watch for planned action Patient becomes self-directed Patient takes responsibility Group and individual instruction Lively & cheerful (posters, music, noise) Normal pace Frequent/fluid transitions
  Therapies	Therapies
  Small groups (non-verbal activities) Short sessions (to match short attention span) Experiential (learn by doing) Behavioral	Large groups (with verbal processing) Long sessions (to match normal attention) Solution-focused Cognitive Behavioral

• Sophisticated neuropharmacological treatments geared stabilizing brain function and providing adequate control of explosive aggression and impulsivity, to remove or overcome the neurological barriers to successful treatment of these psychiatric disorders. Medication is targeted at specific areas of the brain.

• While chemical restraints may be used for safety, the goal should be to treat the underlying brain disorder. 

• The treatment environment is also modified to take into account the fact that individuals with neurodevelopmental disorders are easily overstimulated. 

• The milieu is quieter and slower-paced, with many rest periods built into the schedule. 

• Limit setting is accomplished without confrontations that can lead to rage behavior. 

• It is a nurturing, rather than an authoritarian milieu, with an emphasis on redirection.

• There should be positive praise when control is achieved. 

• There should be a concerted effort to avoid a punitive program, and all negative behavioral consequences (not necessarily safety precautions) should be kept brief (15 minutes to 24 hours at a maximum). 

• Social skills training and anger management should be an integral part of all nursing plans. 

• There should be a focus on avoiding power struggles, by encouraging negotiation to obtain needs and decreasing negative attention, by “picking battles”. 

• Staff use a positive approach, by telling service recipients what to do, rather than what not to do. 

• Staff should help service recipients gain insight into their coping skills and work to increase trigger awareness.

• The Safe Behavior System is used, where the emphasis is on safe behavior and then more advanced treatment goals. 

• When someone is unsafe the only goal is to get safe. The 2/4 rule is used. 2 hours away from peers to de-escalate and 4 hours restricted to the unit.

• Once safe, the goal is to be “on plan” or meeting goals. Once “on plan” the goal is to stay “on plan”. 

• A variety of teaching and behavioral shaping methods are used, including

• Redirection- staff tells the service recipient what to do, not what to stop doing

• Modeling and Demonstration

• Mentoring- a certain staff provides individualized support for one service recipient.

• Co-regulation- staff shows caring and affection, predicts needs and wants, and provides caring support during times of stress or crisis

• The 2/4 rule

• Activity by Activity- The service recipient will be held back from the next activity if disruptive or unsafe during the previous activity

• Time-outs

• Direct teaching

• Role-playing

• Redos or Do-overs

• Restorative actions or repairs

• Collaborative Problem Solving- engages staff and service recipients in a discussion to find more effective responses to impulsive misbehaviors

• Staff uses an 80/20 rule which means 80% of the time they are providing praise and positive reinforcement and only 20% of the time, mild and brief consequences

• Service recipients accumulate points to turn in at a points store for small tangible items and/or weekly points that can be cashed in for “big ticket” special privileges and rewards. 

• Service recipients do not lose points; they only earn points

• Service recipients do not need to earn treatment or daily activities, such as meals off the unit and passes with family.

• Well-defined logical consequences leveled at the severity of the problem behavior may be used in moderation. 

• Each unit has two dayrooms. Service recipients are assigned to a dayroom based on their developmental age, level of functioning, and diagnosis. 

• Sometimes there is not a good fit, and a dayroom reassignment may be considered and/or undertaken.

• Developmentally younger service recipients who have more severe skills deficits are assigned to a dayroom with program and group content suited to their needs. 

• There is a highly structured daily schedule.

•  To effectively help these service recipients navigate transitions between activities, staff gives 15, 10, and 5-minute warnings before the change of activity. 

• The physical environment is modified to take into account safety concerns, have lots of space, address sensory concerns (e.g. noise),  and reduce traumatic associations. 

• There is a staff-to-service recipient ratio of 1:5.

All programming is modified to take into account the patient’s neuropsychological limitations as identified on initial assessments