Counsel, Don’t Just Medicate, the Dually Diagnosed

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The December 22, 2011, edition of the New York Times brings out another article on the problems and abuses in New York State public groups homes where developmentally disabled persons reside. It is important to note that the focus of the NYT articles has been on “public” rather than private group homes. Many of the private agencies offer good to outstanding care.

Although it notes very troubling, even abusive practices, the Times article may not represent psychiatric medical practice in places other than public New York State group homes, and it brings to mind how medicines and behavior therapies have become the standard treatment for those with psychiatric problems and developmental disabilities. Short-term cognitive therapies may be used, but are limited due to the intellectual limitations of these persons.

My own background has emphasized using long-term therapies with a relationship component. I suspect that this kind of therapy continues to hold great promise for those with developmental disabilities. Sometimes psychological testing can depict the rich internal lives of developmentally disabled persons who struggle with psychiatric problems. Here is one example* of a person whose psychological testing suggested she might be a good candidate for supportive therapy.

“Alice is a 45-year-old dually diagnosed client who displays mental health needs as well as needs for a structured setting to address her developmental disabilities. Her most recent psychiatric diagnosis, given during her stay at the psychiatric hospital, was bipolar disorder. The hospitalization was precipitated by an aggressive outburst, which reportedly was accompanied by homicidal and suicidal ideation. She was placed on Lithium at the hospital. Staff report she can become quite upset at small provocations, but calms down when spoken to individually.

“Alice’s response to projective tests shows a wide range of emotional functioning, from immature/regressed responses to adult-like ‘normal’ precepts. These assist in understanding her “stream of consciousness” and provide clues toward developing effective therapeutic interventions.

“On the Incomplete Sentences Blank, a number of responses were given that indicated hopelessness and depression, including: ‘At bedtime…I can’t sleep’; ‘I feel…like a lost child…lost’; ‘My greatest fear…is fear of myself’; ‘My nerves…get the best of me’; ‘My mind…is all confused’; ‘What pains me…I’m going through emotional crisis’; ‘I hate…myself for what I’m going through’; ‘I secretly…am depressed.’ Alice is self-reflective and obviously aware of the pain she is experiencing. She is quite articulate about this: compellingly so, when one considers that her last IQ was in the mild range of mental retardation.

“On the Rorschach, there are many ‘normal’ and calming responses rapidly followed by violent and upsetting ones. This flip-flopping (or lability) is a characteristic of her thinking that occurs throughout testing. On the TAT this occurs also. For example, there are stories involving ‘tearing someone apart,’ ‘a person with daggers in her eyes,’ and ‘somebody who is plotting murder.’ Yet right after these upsetting themes there are calming ones such as ‘here’s a happy ending, they fall in love and get married’ or ‘this one: a daughter who thinks her mother is a lovely lady.’ Because of the intensity of her frightening thoughts, one goal for Alice could be to help her discriminate thoughts from actions. Such discrimination would help desensitize her to some of the violent impulses she experiences. As Alice learns that she can experience thoughts and feelings, and not act on them, she will gain a greater measure of self-control.

“Alice’s fantasy life frequently shows a regression to themes of childhood. These memories surfaced on both the Rorschach and TAT. For example, on Card III of the Rorschach, she saw ‘people having a toffee pull,’ and during the inquiry she elaborated upon this by saying that her mother used to have toffee pulls. On Card VI she saw a ‘bearskin’ and recalled ‘my father who used to go shooting bear.’ Her TAT stories contain excursions back to childhood, and these express a nostalgia for things that were wonderful, where there were loving parents, as in this story: ‘Daughter thinks her mother is a lovely lady.’

“Despite Alice’s memories and yearning for a wonderful childhood, there’s evidence that her real childhood was not wonderful, perhaps even traumatic. For example, on another TAT story, she described a little boy ‘who was going to get a whipping.’ Upon further questioning, she said that ‘my mom hit me with a curtain rod’ and ‘put me in the clothes closet until I behaved myself. It was frightening.’

“Some suggestions for counseling include: make statements that help Alice become calmer; help her locate positives in her past: when she felt loved; identify any ‘universal’ feelings or themes, that is, emotional reactions common to all of us; teach her cognitive restructuring and how to turn negatives into positives; provide positive feedback concerning daily situations where she has displayed self-control; help her distinguish between thoughts and actions.”

The above report suggests the great potential for long-term supportive counseling to help developmentally disabled who experience psychiatric problems. Medication and behavior therapy, no matter how expertly provided, cannot help to affirm, acknowledge, and nourish the sources of healthy functioning sometimes undiscovered among depression or bipolar disorder or other major psychiatric illnesses.

*From J. B. Mordock and W. Van Ornum, (1989), “Evaluating the Dually Diagnosed Client.” In R. J. Fletcher and F. J. Menolascino, (1989), Mental Illness and Mental Retardation, Toronto: Lexington Books.

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