1. How to Talk So Mental Health Will Listen Shaping Supports to Fit the Person Jeff Sneddon, LCSW

2. Introduction Who am I and why am I here? Context of Presentation Review Some Facts

3. Agenda  What is currently in our bag of Tricks  The Why’s and How’s of Mental Health Assessments  Diagnostic Process and Difficulties  What is Therapy, What do we Want, and What do we do?  Working with insurance, CCO’s  Open discussion and problem solving  Evaluation

4. What is currently in our bag of tricks: Objectives Review the critical components of Case Management Services that we have at our disposal for use in referring individuals for Behavioral Health Services and Advocacy.

5. What is currently in our bag of tricks? American with Disabilities Act ◦ Title II Section 201-204 Rehabilitation Act ◦ Section 504 Oregon Revised Statutes ◦ ORS 659A.103 and 659A.142 Oregon Administrative Rules ◦ 309-011-0070 thru 309-011-0095 Person Centered Planning and Referral Process Development and Monitoring of Plans of Care.

6. Bag-O-Tricks: ADA An individual with a disability who, with or without reasonable modifications to rules, policies, or practices…, meets the essential eligibility requirements for the receipt of services or participation in programs or activities provided by a public entity shall by reason of such disability be excluded from participation in or be denied the benefits of…

7. Bag-O-Tricks: ORS It is the public policy of Oregon to guarantee individuals the fullest possible participation in the social and economic life of the state…to participate in and receive the benefits of the services, programs, and activities of state government…without discrimination on the basis of disability; and It is unlawful practice to exclude from participation in or deny the benefits of the services programs or activities or to make any distinction, discrimination, or restriction because of a disability.

8. Bag-O-Tricks: Rehab Act Agencies that receive Federal financial assistance can not deny individuals the opportunity to participate in or benefit from programs, services or other benefits.

9. Bag-O-Tricks: Person Centered Planning and Referral Process Person Centered Planning looks at an individuals wants, needs, and desires systemically with input from families, friends, and paid care givers. Address unmet needs and make referrals to resources to secure unmet needs. Ability to provide critical information to resources to assist in accessing services and supports.

10. Bag-O-Tricks: Plans of Care Case Managers/Personal Agents assist in the development of plans of care and individualized measurable goals to meet an agreed upon outcome. Case Mangers/Personal Agents Monitor the plans of care to and continue to address any unmet needs or provide guidance for revision.

11. Assessments: Objectives Understand what a Bio-Psycho-Social Assessment includes. Know how to prepare ourselves to be able to assist with providing assistance and support to our consumers.

12. Bio-Psycho-Social Assessment Important basic questions to know:  What is the primary concern?  How long has this been occurring?  How often does this happen?  Has there been a recent significant change  or event?  Are there any other behaviors of concern?  Are there any medical conditions or medications?  What is the developmental and social history?

13. Bio-Psychosocial Assessment Domains  Identification and Chief Complaint  Biological  Psychological  Social  Environmental  Risk Factors  Mental Status Examination  Clinical Formulation  Diagnosis  Recommendations for intervention

14. Diagnositics: Objectives Increase our understanding of the diagnostic process. Understand how modifications can be made to criteria.

15. Using the DSM Three factors when using the DSM 1. It only describes particular conditions – it does not provide intervention strategies 2. There can be some tendency to focus on the individual pathology instead of on a client’s interaction with the environment 3. Third reason for wariness when using the DSM concerns imperfections in its categories – individuals and their behaviors are complex and difficult to place in neat, compact categories.

16. 16 Major Diagnostic Classes 1. Disorders Usually first Diagnosed in Infancy, Childhood or Adolescence 2. Dementia, Alzheimer, and other Cognitive Disorders 3. Substance Related Disorders 4. Schizophrenia and other Psychotic Disorders 5. Mood Disorders 6. Anxiety Disorders 7. Somatoform Disorders 8. Factitious Disorders

17. 16 Major Diagnostic Classes ctd. 9. Dissociative Disorders 10. Sexual Disorders 11. Eating Disorders 12. Sleep Disorders 13. Impulse Control Disorders 14. Adjustment Disorders 15. Personality Disorders 16. Mental Disorders Due to a General Medical Condition not Elsewhere Classified

18. Multi-Axial Classification System Axis I: Clinical Disorders Axis II : Personality Disorders & Intellectual Disability Axis III : Current general medical conditions Axis IV : Psychosocial stressors Axis V : Global Assessment of Functioning

19. Diagnostic Complications Diagnostic Overshadowing Intellectual Distortion Psychosocial Masking Cognitive Disintegration Baseline Exaggeration

20. Diagnostic Overshadowing A phenomenon where clinicians attribute behavior to the developmental disability and not to a co-existing mental illness symptom. ◦ An individual with profound ID believes that they can drive a car.

21. Intellectual Distortion Concrete thinking and impaired communication result in poor communication about their own experience (Sovner, 1986). ◦ Individual describes self as ‘scared’ instead of ‘mad’ because of poor verbal skills.

22. Psychosocial Masking Impoverished social skills and life experiences result in unsophisticated presentation of a disorder or misdiagnosis of unusual behaviour as a psychiatric disorder (Sovner, 1986). ◦ Giggling and silliness is misdiagnosed as psychosis.

23. Cognitive Disintegration Bizarre behavior is presented in response to minor stressors that could be misdiagnosed as a psychiatric disorder (Sovner, 1986). ◦ A client is highly disruptive and complains a lot after a preferred staff member leaves, but is diagnosed with schizophrenia.

24. Baseline Exaggeration Prior to the onset of a disorder there are high levels of unusual behaviors, making it difficult to recognize the onset of a new disorder (Sovner, 1986). ◦ A person who already had poor social skills and was withdrawn becomes more so and begins to experience other signs and symptoms of depression. This is missed because staff reports are inaccurate and staff turn-over means that no- one is aware of the overall change in the person’s functioning.

25. Putting it all together Present a solid case for treatment Discuss the ramifications of the lack of treatment Benefit vs Accommodation Inquire about specialization and ask for a referral Sell yourself, MH does not like to do CM Discuss how you can facilitate a IDT to support the clinical work Literature is one sided Developmentally appropriate services

26. Helpful Links: Child Development Institute: http://childdevelopmentinfo.com/ http://childdevelopmentinfo.com/ Online Mendelian Inheritance in Man: http://omim.org/ http://omim.org/ AAIDD Reading Room: http://www.aaidd.org http://www.aaidd.org

27. Evaluation and Goodbye Jeff Sneddon, LCSW jsneddon@co.linn.or.us