NADD Bulletin Volume XI Number 1 Article 3

Complete listing

The intersection of best practice in dual diagnosis and positive psychology

Daniel J. Baker, Ph.D.

E. Richard Blumberg, Ph.D.

In this paper, we will describe positive psychology and note the contributions that positive psychology offers to support for people with the dual diagnoses of an Intellectual or Developmental Disability and a Mental Illness. It is important to consider the many parallels between dual diagnosis supports and positive psychology.

Positive psychology is a branch of psychological inquiry that focuses on the experience of positive emotion and the role of healthy emotions in daily life (Seligmann, Steen, Park, & Peterson, 2005). Psychology as a whole has been criticized as a field in which illness is studied rather than wellness. Negative emotions are the unit of analysis rather than positive emotions. Positive psychology researchers have amassed data to show that therapeutic interventions based on positive emotion can produce rapid improvements in mental health (Seligmann, Steen, Park, & Peterson, 2005).

While consideration of positive emotion has been a feature of psychology for quite some time (Rogers, 1951), positive psychology has gained increasing attention in recent years. Due to the accumulation of empirical data, the appeal of the philosophy, and the simplicity of interventions, significant public attention has been given to positive psychology, culminating in a 2005 cover story in Time Magazine of positive psychology entitled, “The Science of Happiness” (Wallis, 2005).  While Time Magazine may not be known for its focus on empirical science, it is a measure of the appeal and effectiveness of positive psychology. Positive psychology offers many proven interventions and provides significant resources for the study of positive emotion (Linley & Joseph, 2004).  The Character Strengths and Virtues: A Handbook and Classification (Peterson & Seligman, 2004) provides a categorization of the traits that are seen as contributing to happiness.  Interestingly, the traits have been shown to be replicated across cultures, suggesting that there is a commonality in human experience. This echoes the cross-cultural research that lead to the Wellness Scale entitled "What is right with your life?" (Cannon, 1997). Critically, this research directs us to empirically validated interventions that improve positive emotion and reduce negative symptomatology (Seligmann, Steen, Park, & Peterson, 2005). For example, one proven intervention is an exercise in which research participants were asked to write down three things that went well and the causes for those things every night for one consecutive week.  The focus on strengths in positive psychology mirrors a similar movement in the study of supports for persons with disabilities, which will be detailed briefly in the next section of this paper.

Disability-related Supports

The philosophy and theoretical underpinnings of supports for persons with Intellectual or Developmental Disabilities (IDD) have changed dramatically in recent years. Prior to the 20th Century, there were few services for persons with developmental disabilities, but there were few specialized services for any person. As civilizations and cultures began to include specialized professions and areas of learning, resources for persons with a disability began to emerge. Some examples include the Oral School for the Deaf established by Samuel Heinicke in 1755, the Massachusetts Asylum for the Blind opened in 1832 (later renamed the Perkins School for the Blind), which offered the first residential instructional and training program for "idiotic" children in 1848, and the establishment of special education classes by the State of New Jersey in 1911. Each of these “places” in which persons with disabilities lived or were educated was created based on the perspective that the individual had a deficit of some sort, and a “place” was created where that person could have that deficit addressed or somehow ameliorated. In a similar vein, institutions and therapies were developed to ameliorate psychological problems.

The growth in services and supports for persons with disabilities created an impetus for the creation of a class of professionals working in this burgeoning industry. A science of habilitation and rehabilitation was established. The National Committee for Mental Hygiene was founded in 1909. Additionally, the rehabilitation of injured veterans drove systemic improvements. In 1918, the Smith-Sear Veterans Vocational Rehabilitation Act authorized the Federal Board for Vocational Education for World War I veterans who had acquired disabilities during combat or other military service, putting significant federal funds behind rehabilitation and thus creating rehabilitation professionals and governmental systems. Once again, the rehabilitation practices and sciences were developed in order to address a deficit within the person, occurring congenitally or occurring during a person’s lifetime.

A theme throughout all of these systemic improvements has been the identification of some type of deficit, labeled a disability, and then the creation of services to address or ameliorate that disability. This philosophy of support necessitated the creation of different groups of professional, best practices, and skill areas (Benjamin, 1989).  Different institutions were established for people with different types of disabilities, and different training programs were created in which professionals could learn the technologies for each. Professional journals were established, such as Journal of Psycho-asthenics (1912) with its lead article, “A revision of the Simon-Binet system for measuring the intelligence of children” (Kuhlmann, 1912), and the book Mental Defectives: Their history, treatment, and training published in 1904 (Barr, 1904).

In more recent times, however, the philosophy of support has shifted away from the identification of a deficit and the subsequent design of interventions to address that weakness. An essential concept in the development of the support paradigm is the principle of normalization. First articulated by Bengt Nirje of Sweden, Wolf Wolfensberger brought the idea to the United States in the 1960’s. Nirje (1985) proposed that normalization meant making available to all persons with disabilities, regardless of the severity of their disability, patterns of life and conditions as similar to, or the same as experienced by non-disabled individuals.

         In the mid 1980’s, the broad realization emerged that with appropriate supports, even people with significant disabilities can live and be fully included in the activities of their community (Lakin & Bruininks, 1985; O’Brien, 1989). This concept was reinforced by the enactment in 1990 of the landmark Americans with Disabilities Act which mandated that accommodations be made by community entities such as schools, businesses, and public transportation to ensure people with disabilities enjoy their full rights as citizens.

Supports for persons with IDD have switched to an approach in which a person’s strengths are identified, and the strengths and interests become the focus of support for the person, rather than focusing on the deficits, which are often difficult to change in persons with IDD. Consider as an example employment supports for persons with IDD. Previously, if a person was identified as having IDD, often, the individual spent a significant part of their work life in a place where other persons with IDD went to work. The person was deemed unemployable in the general community and went to a sheltered workshop (Close, Sowers, Halpern, & Bourbeau, 1985). In supported employment, the focus instead is on finding what the person is good at and what the person wants to do, and then locating an employment position in the community where the person’s work abilities will contribute to an employer’s business (Nisbet & Hagner, 1988).  While the concept of supported employment has not changed work life for all persons with IDD, a sizable number of persons with IDD are employed in community (Larson, Lakin, & Huang, 2003). With recreation for persons with IDD, rather than noting that a person has IDD and then enrolling the person in a specialized recreation program, the question would be what types of recreation does the person enjoy, and how can the person access those kind of activities in the community.

In no way does this approach to disability supports ignore the presence of a disability, but the starting question changes. It is no longer, “what is wrong with you and where do we send you to get you fixed.” The question is “what do you want to do, what are you good at, and how do we figure out how to access it.”  Accessing the community site becomes an issue of teaching the individual with IDD requisite skills and creating proper, necessary accommodations. Note the tremendous degree of overlap with positive psychology, which asks the same kinds of questions.

There are many methods of asking the initial questions about what a person is good at and what a person wants to do. The strategies for accomplishing this are often referred to as methods for “Person-centered Planning.” O’Brien and O’Brien (1998) provide an excellent overview of different methods of person-centered planning. Some key themes of all the different strategies include: (a) a focus on identifying the skills and interests that the person has, (b) identifying resources that the person can use, (c) working with individual to identify specific support needs, and (d) arranging support to address those needs.

The supports that a person uses often are arranged to increase a person’s sense of wellness and improve the individual’s quality of life (Brown, 1988; Sheppard-Jones, Prout, & Kleinert, 2005). Supporting a healthy lifestyle and culturally typical levels of activity are often the desired outcomes of supports for persons with IDD. This includes the strategies used in addressing problem behaviors among persons with IDD. Recent approaches to addressing problem behavior also start with identification of strengths and interests rather than simply focusing on the problem behavior (Horner, et al., 1990). Intervention targets strength based planning, support identification, teaching and wellness approaches, rather than simply reducing frequencies of problem behavior.

Positive Behavioral Support

Perhaps the most compelling example of the intersection of disability supports and positive psychology is the set of values and practices referred to as Positive Behavioral Support (PBS).  In recognition of the complex, ever changing influences upon human behavior, PBS emerged from the field of Applied Behavioral Analysis  in the 1970’s and has generated a rich and varied literature of research and methodology. PBS incorporates person centered values and a concern for individual dignity, in an effort to create environments and supports that promote a person’s capabilities, expand opportunities, and enhance lifestyles (Koegel, Koegel & Dunlap, 2001). PBS utilizes multiple methods of assessment to create a useful understanding of a person’s wellness, the quality of the current environment and routines; individual learning style and functional skills; and existing relationships and supports. Functional assessment information results in a holistic profile of the individual for the purpose of creating supports and environments that enable a person to develop needed skills to achieve personally meaningful goals (Janney & Snell, 2000).

The intersection of Positive Psychology and Dual Diagnosis Supports

A review of the philosophy of positive psychology shows that there is considerable overlap in positive psychology and best practices in supports for people with the dual diagnoses of IDD and MI. For example, both often focus on the strengths of the individual. Additional, both look to identify factors that lead to success. Both have the philosophy that proper treatment needs to be provided, but that the best success comes from enhancing a person’s strengths. Supported employment has an axiom that nobody ever gets a job because of what they can’t do; they get jobs because of what they can do.

As noted previously, one of the reasons for the rapid growth in positive psychology is the fact that the interventions are simple, as well as being effective. Seligmann, Steen, Park, and Peterson (2005) describe the results of a large empirically-controlled study in which they evaluated the effectiveness of positive psychology interventions. For example, one empirically validated intervention was an exercise in which research participants were asked to write down three things that went well and the causes for those things every night for one consecutive week. A second intervention involves using “signature strengths” in a new way, in which participants were asked to take an inventory of character strengths and find new ways to use the most important of those strengths in a new way. These are simple interventions that do not require an office visit. Most persons would enjoy an exercise such as this. Furthermore, this is an exercise that could be easily adapted for persons with IDD and MI using strategies described by Morasky (2007) and Munro (In press).  The author has used these strategies in clinical practice, and has seen a growing body of experience suggesting clinical utility. The strategies of the Signature Strengths practices seem to be the most useful and are simplest to use with persons with have the dual diagnoses of IDD and MI. In limited clinical practice, the Three Good Things exercises do require some degree of memory that will require additional accommodation for learners with more significant intellectual disability. 

References

Barr, M.W. (1904). Mental Defectives: Their history, treatment, and training. P. Blakiston’s Son & Co: Philadelphia, PA. 

Benjamin, S. (1989). An ideascape for education: What futurists recommend. Educational Leadership, 47, 8-14.

Brown, R.I. (Ed.) (1988). Quality of Life for Handicapped People. New York: Croom Helm.

Cannon, J. (1997). What is right with your life? Monterrey, CA.: Inward Bound Ventures.

Horner, R. H., Dunlap, G., Koegel, R. L., Carr, E. G., Sailor, W., Anderson, J., Albin, R. W., & O’Neill, R. E. (1990).  Toward a technology of “nonaversive” behavioral support. Journal of the Association for Persons with Severe Handicaps, 15, 125-132.

Janney, R. & Snell, M. Behavioral Support. Baltimopre, MD: Paul H. Brookes

Koegel, L., Koegel, R., & Dunlap, G. (1996) Positive Behavioral Support. Baltimore, MD: Paul H. Brookes

Kuhlmann, F. (1912). A revision of the Simon-Binet system for measuring the intelligence of children, Journal of Psycho-asthenics, 1(1), 3-41. 

Larson, S., Lakin, C., & Huang, J. (2003). Service Use by and Needs of Adults with Functional Limitations or ID/DD in the NHIS-D: Difference by Age, Gender, and Disability. DD Data Brief, Minneapolis: University of Minnesota, Research and Training Center on Community Living.

Linley, P. A., & Joseph, S. (Eds.). (2004). Positive psychology in practice. Hoboken, NJ: Wiley.

Nirje, B. (1985) The Basis and Logic of the Normaliztion Principle. Austrailia and New Zealand Journal of Developmental Disabilities, 11, 65-68

O'Brien, J. (1989) What's Worth Working For? Leadership for Better Quality Human Services. Lithonia, GA: Responsive Systems Assoc.

O’Brien, J., & Lyle O’Brien, C. A Little Book About Person Centered Planning. (1998) Toronto, ONT: Inclusion Press. 

Morasky, R. (2007). Making counseling/therapy intellectually attainable. The NADD Bulletin, 10(3), pp. 58-62.

Munro, D. (In press). Couple therapy and support. The NADD Bulletin.

Nisbet, J., & Hagner, D. (1988). Natural supports in the workplace: a reexamination of supported employment. Journal of the Association for Persons with Severe Handicaps, 13, 260-267.

Peterson, C., & Seligman, M. E. P. (2004). Character strengths andvirtues: A handbook and classification. Washington, DC: American Psychological Association.

Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications,

and theory. Boston: Houghton Mifflin.

Seligman, M, Steen, T., Park, N., & Peterson, C. (2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 60, pp. 410–421.

Sheppard-Jones, K., Prout, H.T., & Kleinert, H. (2005). Quality of life dimensions for adults with developmental disabilities: A comparative study. Mental Retardation: Vol. 43, No. 4, pp. 281–291.

Wallis, C. (2005). The new science of happiness. Time, January 17.