Ian Gilmour & Greg Gravelle
People with a dual diagnosis and their caregivers find it difficult to secure the services they feel would support them in successfully resolving crises (Gravelle, 1996). There may be several reasons for this: some communities lack quick response/crisis services for the dually diagnosed; access to other therapeutic services may be restricted due to low availability or a misunderstanding of the benefit that people with a dual diagnosis would derive from these services. Without specific therapeutic supports, many agencies supporting people with a developmental disability are hesitant to serve people with a dual diagnosis. This situation presents, for consumers and their families, a series of almost insurmountable problems.
The Dual Diagnosis/Crisis Team at Community Resource Services was created out of existing behavioral support resources to respond to the needs of persons with a dual diagnosis, pervasive developmental disorders, and those labeled hard to serve due to aggressive or dangerous behaviors. To respond to the needs of these individuals, their families and group homes, we collaborate in identifying the organizational/systemic, environmental, family and personal strategies that help them get unstuck from the problem. All interventions are non-intrusive, educationally based and designed to ensure dignity and respect for caregivers and the people we support. We believe that our clients, like everyone else, want to make sense of their world and live a happy life (Risley; 1995). However, sometimes, the means they choose to meet their needs inadvertently creates havoc for themselves and the people around them. While we acknowledge that the disabling condition exerts a profound influence on the individuals interior and exterior life, we agree with Hollins, Sinason, & Thompson, (1994) that people can not solely describe the person by that condition.
Three levels of team involvement
Problems are complicated entities which have multiple components and pose both personal and organizational challenges for the individual and caregivers. In our experience, people with a dual diagnosis, PDD or labeled hard to serve are highly vulnerable and if we do not help develop plans that account for both the personal and organizational level, people do not do as well. The Team provides three integrated and iterated service paths: support clusters, identification of systemic resources, and brief, time limited therapy:
1. Support clusters/Wraparound
The Dual Diagnosis Team has been experimenting with supporting the most vulnerable individuals through combining systemic and individual interventions. The support cluster model is designed to accomplish two immediate outcomes. First, it attempts to reduce the social isolation that dual diagnosis brings to the individual and their family. A support cluster using formal and informal community support systems can achieve, at an organizational/systemic level, outcomes complementary to brief therapy at the individual level. It allows for a lack of blame about the problem. A support cluster organizes what we know about clients in a way that minimizes pathology as an explanation; it uses the self resources of its members, their community connections, reorganizes communication among members, provides support to the supporters, and creates a holistic picture of the individual being successful within the community. Together, the individual, caregivers, professionals, and interested people make something different happen in the individuals life. The second outcome is the recognition that to act differently, people need to feel competent, to self regulate. The Support Cluster finds a way through the extended community support system to find out what the person wants and helps him or her to get it. Like the Wraparound concept (VanDenBerg, 1993) the planning is based on the needs of the individual and care system. It always begins with an assessment of strengths within a variety of life domains. It overcomes barriers to happiness, person-environment fit, and inter system conflict between service providers and the care system.
2. Identification of systemic resources
At times, the needs of the individual and care system are so acute that the system needs to mobilize support immediately. A variety of paths might be explored to meet the need such as an infusion of short term money, the assignment of a crisis case manager, a clinical intervention, or use of a short term crisis bed. Systemic resource identification acts to clarify what resources are available and can be brought on-line in a crisis modality. This may be reorganizing existing services to meet immediate needs or to start a process to identify scarce longer term resources such as psychiatric, psychotherapeutic or behavioral support.
3. Brief, time limited interventions
On the individual/family level, the team initiates brief, time limited interventions, lasting 12 contact hours to help caregivers and clients develop new strategies to change relationship and communication patterns as a way of becoming unstuck from problems. Our therapeutic process intermingles ideas and techniques from solution focused, positive behavioral support and strategic family therapies.
The core of our therapeutic process is the collaborative team. This is composed of the caregivers and Team therapists. The collaborative teams first task is to explore the beliefs and environmental arrangements which contribute to the current view of the problem. We believe that how people interact with the problems whether they are angry, afraid withdrawn or obtuse reflects the tacit beliefs of what the problem says about the individual. On the topic of tacit knowledge, Mahoney (1989, p.25) writes:
There is a powerful and synergistic relationship between the quality of our life experiences and the structures and processes of our private and predominantly tacit (non-verbal, unconscious) theories of ourselves, our worlds and their possible interactions. Our private assumptions and ingrained beliefs constitute ever present anticipations and constraints on what and how we experience.
The way caregivers and clients organize around symptomatic behaviors result in an emotional organization in which the development of goals can reflect a sense of control and competence among caregivers or when caregivers feel overwhelmed can come to mirror: (a) their anxiety about the client as the problem; (b) their need for control; and, (c) the belief that the problem reflects either a choice on the part of the client, that it is a manifestation of the disability or is indicative of the persons personality. These are goals and views which speak to the power of the problem not of the participants. Together, we describe not prescribe, how people feel, how they want to be supported and what resources they have to change the problem.
There are three ideas that guide our hypothesis formation and intervention strategies. Jay Haley has said that you need one theory to understand a problem but a different one to solve it (quoted in Simon, 1995). Similarly, Gregory Bateson (quoted in Parry and Doan, 1994) noted that you need to create a sense of what is different between one thing and another, between a problem and a solution. Finally, the idea that therapeutic interventions are about shifting attention from problems to helping the individual (and caregivers) live the life they wish to lead. This is, we believe, an emergent theme in positive behavioral support, albeit in somewhat different language. A focus on helping people change their lifestyle to what they wish it to be instead of fixing or solving a problem. (Albin et al 1996).
In helping people live the life not dominated by problems, we make several assumptions about the capacity of caregiver and clients to deal with those problems differently. We act consistently with the idea that they are the experts on their relationship and lives together and can identify the resources and answers they need to deal with the problem. We think that caregivers can step away from the problem and recognize when it does and doesnt occur. This creation of distance and a sense of control and competence is more satisfying and leads to discussions around three important points: first, they choose to start the process and are responsible for it; secondly, the problem is separate from them, neither caregiver nor client is the problem; and, third, to recognize the solution may be already occurring but unnoticed. As the problem becomes an external force to be dealt with rather than an internal defining characteristic, new questions arise. When isnt the problem present and what happens then? When was it expected but did not occur? Problems which were thought of as inevitable and overwhelming become something else. Attention focuses on when things went right.
Identifying Survival/Coping strategies - How people stay stuck:
A primary idea that we advance early in the consultation is that people stay stuck in problems because the strategies they use, interpreted by caregivers as maladaptive behaviors, in fact, are efficient and instrumental in meeting emotional needs and environmental goals. Since the survival/coping strategies ensure that the person gains their expected outcomes, their success make the problem feel inevitable for caregivers. As caregivers try to extinguish a response, the individual successfully uses their set of survival/coping strategies to meet needs and goals unknown to the caregiver. Any solution the caregiver devises is tied more and more to the person stopping the behavior rather than restructuring environments, relationships and communication which would allow needs to be met in less disruptive ways. It is often difficult for caregivers to see the relationship of their use of consequences to the maintenance of the problem (Luiselli, 1996). In response to these feelings of being overwhelmed, the consequences levied by caregivers can become a response not to the problem but to their growing frustration with the individual. The use of survival coping strategies are strengthened for the individual in at least two ways. They likely have a self regulation function such as anxiety reduction, or is a behavior that the individual uses to feel competent and in control of themselves. By trying to suppress the inappropriate or maladaptive behavior the caregiver inadvertently reinforces the function of the individuals use of the strategy. Or, the caregiver, in interrupting an internal ritual of the individual occasion more intense acting out behaviors as the individual increases their behavioral output to continue to manage anxiety or feeling of incompetence. Caregivers have no idea of their role in strengthening the survival/coping strategy. All they see is that the behaviors are becoming stronger and more resistant to their interventions while they feel a sense of failure. On the part of caregivers and clients, there is an acceptance that the behavior reflects the personality, choice or the disability of the client.
At the beginning of an intervention, we often find caregivers who want something to change in their relationship with the client but who are so over rehearsed in the problem that they are unable to go beyond the problem story. We ask caregivers to tell us the story in a different way. We do that for three reasons. First, by asking themselves why certain behaviors occur in some situations and not in others, caregivers make the decision to step back and view the environment differently, to see the forest within the trees. Second, as a rapid way for the collaborative team to map the person-environment, that is to say how events, activities, physical settings and people influence the emergence of both problem and solution behaviors. Finally, to co-create with caregivers, hypotheses about environmental/personal events, communication/relationship patterns and predominant survival/coping strategies. The use of hypotheses help caregivers test person-environment fit and reframe ideas and discussion from a problem orientation to when solution behaviors are already occurring. These three outcomes, we feel, challenge the idea of the individual as the problem and having done that, the caregiver can take a second look at the problem hopefully seeing it as neither inevitable nor overwhelming. The three areas examined in this process are:
1. Person-Environmental Fit
This includes aspects of the physical and social environment interacting with the person. Albin, Lucyshyn, Horner and Flannery (1996) have noted several environmental features which we also examine. These are , the physical layout of the environment, the number of different people in the environment, typical routines and activities in the environment, schedule of events or activities and curriculum characteristics and demands.
2. Relationships and Communication Strategies
How does the person and caregiver view themselves and act within relationships? What are the communication strategies that they use both verbal and non-verbal means to initiate and maintain relationships, self regulate and feel competent? For us, this very much includes caregiver thoughts, feelings and attitudes towards reinforcement.
3. Intrapersonal Factors
Intrapersonal factors are elements such as disability, related conditions such as anxiety or trauma, cognitive-emotional beliefs all of which influence the individuals ability to forge a good fit with other contexts.
Looking Beyond the Problem: Identifying New Solution
The first intervention strategy, asks caregivers to consider adopting a different theory of the problem. We have asked the caregiver to tell us the problem story while we sequenced it out of order, prompting an examination of the environment, relationships and disability in ways not considered before. What emerges, we think, is a new theory of the problem that is a doorway to a second theory, one where the problem does not dominate. We often find that identifying this second theory, expressed in hypotheses about the function of the survival/coping strategies, helps caregivers forge a new, productive relationship with the individual based in a set of beliefs about people, problems and solutions which form a solution focused approach. Our definition of a solution focused approach is adapted, in part, from Lipchik and Kubicki (1996). It views the people we work with non-pathologically. We make the assumption that people have the strengths and resources to find their own solutions but have reached a point where they perceive themselves as stuck. The language (verbal and nonverbal) used by clients is a source of personal and social reality and is the means towards a future in which clients can perceive solutions. The therapist collaborates with clients in a conversation characterized by acceptance of and curiosity about the clients present reality. The therapist asks questions about exceptions to problems, existing and potential resources and a future in which the problem does not exist. The Team emphasis, unlike a strictly solution focused approach is on Haleys concept of a first theory of problem maintenance. Solutions arise, we believe, in part, when caregivers appreciate that they are also trapped and oppressed by the problem (White and Epston; 1990).
A wider discussion of assumptions underlying a solution focus approach is beyond this paper but is discussed by Walter and Peller (1992), Miller, Hubble and Duncan (1996) and deShazer (1985; 1994). Our adaptation of a solution focused approach, looks at four key areas.
1. The perception of being overwhelmed by the problem and stuck in a certain kind of solution reflects a perception of the problem as insoluble ( I cant get him to stop) This is the situation in which caregivers are so often enmeshed and is reflected by Walter and Pellers (1992, p.12-13) observation that:
People sometimes get stuck into only one set of expectations of what the solution will look like. Other times may be diminished as inconsequential because to their way of thinking, the exceptional times do not represent real solutions or because exceptional times are not consistent.
2. All participants have the resources and strengths to solve problems. Our continuing experience is, as people become unstuck, they are better able to identify when things are different or to challenge the story of the problem, other options, strengths and perceptions emerge which lessen the power of the problem.
3. Small changes lead to larger changes, both in the personal system between individual and caregiver and also at a systemic level. In helping to create a change environment, we ask caregivers to explicitly say what they need to solve the problem rather than joining them in a discussion about why the problem cant be solved. Caregiver discussions about what the client does wrong tends, over time, to locate the problem within the client rather than how the relationships and lives of clients and caregivers become increasingly organized around the problem.
The change made by caregivers is, we feel, one of attitude in what they think the problem means. If the caregiver can take a step back and recognize when the client is doing something different, engaging in behaviors not predicted by the problem story, then they have begun to reorganize what they know about the client in a pattern that excludes the inevitability of the problem. They have, in fact, begun to form the solution theory. We agree with Walter and Peller (1992) that problems are only as large as our definitions about them.
4. There is no client resistance to treatment and that all client cooperation is inevitable. Jay Haley (1976) noted that Milton Erickson approached clients in the sure expectation that a change was not just possible but inevitable. The client and caregiver, by coming to therapy, have already made the decision to examine their lives and to open themselves to the possibility of change. When the decision to seek therapy is made by someone other than the caregiver or client, the role of the therapist is to help caregiver and client decide what they could get out of the therapy sessions and how such a process might make sense for them and can be, the external referral notwithstanding, within their control.
We believe that people, whether clients or caregivers, want to be happy, that their organization of their behaviors around symptoms is an honest mistake and as that becomes apparent they will their interactions to reflect the relationship and communication they really want. Bandler and Grindler have said that there are no resistant clients, only inflexible therapists (quoted in Walter and Peller, 1992:23). If we hear what people want and try to help them achieve it, cooperation is inevitable.
In strategic therapy, problems are viewed as an extended interaction between people. Symptoms are thought of as scripts between people and are seen as essentially adaptive to relationships. The use of strategic therapy provides the Team with another way of talking about how the system organizes itself around the symptomology of the problem. We use it as part of our thinking about survival/coping strategies which are characterized by the adaptive nature of the problem to relationships with the family or group home. For example, in a family we worked with, the overwhelming and predominant relationship was between the mother and child leaving the father peripheral to family functioning . In the retelling of the problem story, it became clear that the underlying goal of the family was to find a way to feel like a family. Unfortunately, all of their functioning as a family was organized around the survival/coping strategies of their autistic child. They knew that to accomplish the role the father would need to take a more central role in family structure creating a different kind of relationship and communication pattern with his child. This idea was, however, very frightening to the mother and in spite of her wish to be a family, the way she ensured that she coped often required her to push the father out of the picture. To help the family become unstuck we used a series of therapeutic tasks. These tasks are activities which the family does outside of therapy sessions, and are designed by the therapists to change the familys approach to the presenting problem in such a way that it loses both its inevitability and insolubility. Our first intervention was not directly related to the presenting problem. We gave, to the mother, who had a long and public history of conflict with professionals, the genuine emotional acceptance she had sought from those same professionals. We were able to acknowledge the fathers lifelong feelings of rejection and sorrow over his childs autism. The therapeutic task we followed up with asked the father to take the job of not being pushed out of an interaction by the intensity of the mother-child relationship. The task for the mother was to support him in staying. The intention of the task was twofold, it was used to facilitate change in how the mother and father related to each other regarding the problem. Second, it was used to deliberately emphasis that the childs problem was a survival/coping strategy. The child, to reduce anxiety and to maintain sameness with in relationships and the environment tended to use the mother as a transitional object. The father, by staying in the situation, was able to demonstrate to the mother his commitment to the concept of family. When he was supported by the mother and included as a means of helping his child self regulate, he began to spontaneously design his own strategies for enhancing the relationship with his child. In another case, a mother was able to feel hopeful about her daughter despite family apathy and rejection of the child. She wanted immediately to be able to share her emotional hope for her child, to see that the girl, who suffered from fetal alcohol syndrome and developmental disability, could be recognized by others in the same way the mother was able to visualize her. Much of the interaction and communication between the mother and daughter revolved around the mothers fear that she was in the process of losing her child to the streets. That sense of impending catastrophe coupled with family skepticism, paralyzed her and her relationship with her daughter. By being able to overcome the fear the mother was able to recognize that protective function of many of the survival/coping strategies used by the child. She was able to change the occurrence of environmental events which precluded the use of negative survival strategies by the daughter. Both the mother and daughter were able to successfully exploit this opportunity to change their relationship.
This paper presented ideas and case examples from a combination of therapies. Community Resource Services-Dual Diagnosis/Crisis Team combines a variety of elements to create a system which helps the client and caregiver access what they need to be successful. It discussed the idea that when interventions, interactions and communication were organized around symptomatic behaviors people tend to perseverate in those types of behaviors. Understanding the clients behaviors as a series of survival/coping strategies allows caregivers and clients to act differently towards people, things, events and ideas. Acting differently facilitates caregivers in understanding the needs of the person and, in matching attempts by clients to meet those needs with behaviors, caregivers are able to successfully reframe behaviors which seemed out of control as in control.
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For further information contact:
Dual Diagnosis/Crisis Team
Community Resource Services
1244 Victoria Street, North. Suite 201,