Nancy J. Razza, Ph.D.
It has now been well established that people with ID suffer from high rates of psychological disturbance (Caine & Hatton, 1998; Fletcher, 2007; Meyers, 1999; Nezu, Nezu & Gill-Weiss, 1992; and Nugent, 1997.) In addition, it has been established that the nature and scope of psychological disorders in people with ID is similar to that experienced by members of the general population (Charlot, 1998; Fletcher, Loschen, Stavrakaki, & First, 2007). In this regard, a growing body of literature bears witness to two important, yet disparate, trends. The first is that a number of therapeutic interventions have been found to have promising results with dually diagnosed individuals (Berry, 2003; Bouras & Holt, 2007; Razza & Tomasulo, 2005; Tomasulo & Razza, 2006; Willner; 2005). Psychotherapeutic techniques have evolved dramatically over the past twenty years, and a range of treatment modalities have now been shown to have efficacy with dually diagnosed persons. Along these lines, interest in the area of dual diagnosis has led to the creation of journals specific to research in this area: Mental Health Aspects of Developmental Disabilities and, beginning in 2008, the Journal of Mental Health Research in Intellectual Disabilities. A further evolution is the production of a specialized diagnostic manual, the DM-ID (Fletcher, Loschen, Stavrakaki, & First, 2007). The DM-ID, a set of companion volumes which includes a textbook as well as a clinical guide, is the result of a joint effort on behalf of the NADD and the American Psychiatric Association, publisher of the most widely used diagnostic text, the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text re.; DSM-IV-TR; American Psychiatric Association, 2000). The collaboration of the American Psychiatric Association in the development of a specialized diagnostic handbook for use with people who have ID attests to the surge in awareness of the mental health needs of this previously neglected group. There is now widespread acknowledgement of both the mental health needs of the ID population, as well as their amenability to psychotherapy, once thought to be of little utility to people with intellectual impairments.
At the same time, however, the availability of mental health treatment for dually diagnosed persons appears to be limited and spotty (McNelis, 2007; VanderSchie-Bezyak, 2003; Werges, 2007). McNelis (2007), co-chair of the US Public Policy Committee, states that the process of deinstitutionalization that has been ongoing since the late 1970s reveals that people dually diagnosed with ID and psychiatric problems are the most difficult to move out of the institutions, and the most likely to be reinstitutionalized. He suggests that this difficulty traces back to the nature of funding and lack of an organized federal initiative regarding the care of dually diagnosed persons. McNelis notes that the Centers for Medicaid and Medicare Services allow individual states to seek funding (i.e., submit Medicaid Waiver applications) on a state by state basis. As a result, each state has developed its own relatively unique service system, with many states struggling to implement a viable plan. McNelis concludes that The anecdotal evidence suggests that there has been an erosion of the ability to support individuals with ID/MI in the community. . . Cuts in mental health services and related supports have decreased the community capacity to serve individuals with a co-occurring intellectual disability and mental illness. . . (p. 111).
Need for Improved Graduate Training
It appears that the limited treatment availability for dually diagnosed persons in the US is due, in no small measure, to the lack of a systematic, federally supported plan for the care of these individuals. A further and equally critical factor is the apparent absence of academic training in graduate programs ( Rush, Bowman, Eidman, Toole, & Mortenson, 2004; VanderSchie-Bezyak, 2003; Werges, 2007). Butz, Bowling, and Bliss (2000) conducted a review of the published literature on the efficacy of psychotherapy with dually diagnosed persons. They concluded that there is a growing body of literature on the topic, but that psychologists need to be better informed about this work. Few professional psychologists receive adequate preparation in the area of mental health in ID, and many feel unprepared to treat individuals with dual diagnoses (VanderSchie-Bezyak, 2003). It seems that the growth in research has yet to make its way into graduate academic training.
A search of graduate training programs and internships suggests that only a small percentage of programs in the U.S. prepare students specifically to treat mental health problems in people with ID. Unfortunately, the number of programs providing training in ID becomes even smaller when the search is limited to programs whose curriculum encompasses a broad range of clinical interventions as opposed to those solely providing training in applied behavioral analysis. It should be noted, however, that those few programs that exist represent an important exception. These programs stand out as models of clinical treatment for dually diagnosed persons.
Importantly, the American Psychological Association asserts a decided interest in including an understanding of disability as it pertains to graduate student training. In Guidelines and Principles for Accreditation of Programs in Professional Psychology, published by the Committee on Accreditation of the APA (2008), it states:
Respect for and understanding of cultural and individual diversity is reflected in the programs policies for the recruitment, retention, and development of faculty and students, and in its curriculum and field placements. . . Throughout this document, the phrase, cultural and individual diversity refers to diversity with regard to personal and demographic characteristics. These include, but are not limited to, age, disability, ethnicity, gender, gender identity, language, national origin, race, religion, culture, sexual orientation, and social economic status(p. 9). The APA does not specify the manner in which these competencies might be achieved. Rather, it notes that, It is the programs responsibility to describe and document the manner by which students achieve knowledge and competence in these areas (p.11).
It may be concluded that this situation is not unlike the lack of governmental policy concerning mental health treatment of people with ID. Each academic institution must develop its own agenda concerning training in disability related issues. Given that the understanding of the mental health needs of people with ID is still young, it is not surprising that this literature, and corresponding clinical training, has not yet been integrated into graduate curricula.
Those of us who work in the field of dual diagnosis, who do research, teach, and provide clinical interventions, have helped to advance the field dramatically over the past 20 years. It is now time to look at taking what we have learned, and working to influence both public policy and academic training. The widespread awareness of the mental health needs of people with ID, people who often have little opportunity and few resources to seek support for their own needs, requires advocacy as much as it does education.
While it is beyond the scope of this article to make recommendations concerning public policy, it can safely be concluded that training in the diagnosis and treatment of mental health disorders in people with ID ought to be incorporated as a standard in graduate curricula in such programs as clinical psychology, clinical social work, and counseling. As more graduates enter the field sensitized to the realities faced by people with dual diagnoses and equipped with the means to help them, a major hurdle will be overcome in the problem of treatment provision to this deserving group of people.
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