Taking the Duel out of Dual DiagnosisWV2021

10/11/21

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Mary Vicario, LPCC-S, Certified Trauma SpecialistFinding Hope Consulting, LLC

Taking the Duel out of Dual Diagnosis:Reflecting, Honoring & Connecting with Individuals with

Intellectual & Developmental Differences

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Success for Our Time Together

Virtual Hack Plans-Please Exit the Meeting.

Mute your mic to reduce background noise, and use the Chat feature.

Approach with curiosity, it engages the cortex.

While certainty engages the fear center. (Baim,

2020)

Being Brave:Lean in or Lean out

Honoring the gifts shared today.

Everyone here is important and unique!

© 2020 Finding Hope Consulting LLC; Mindshift Counseling and Consulting LLC; The Center for Family Safety and Healing

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Objectives: Participants will be able to identify and address:

The many and varied ways our brains and bodies experience, process and make sense of the world around us.

The needs and drives behind “The Five Purposes of Behavior.”

The hidden resilience in commonly learned survival strategies like lying, stealing, manipulating, aggression and defiance.

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Objective 1:

Participants will be able to identify and address the many and varied ways our brains and bodies experience, process and make sense of our world.

Experiencing the World Through Your Eyes:

The Many Ways Our Brains & Bodies CanExperience, Process & React to the

World Around Us.

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THE HAND BRAIN

Wrist to elbow = Spinal Column & Vagus Nerve, which sends feelings to every organ in your body.

Thinking Brain (Cortex) = Our Upstairs Brain

Reacting Brain = Our Downstairs Brain (Limbic System) The Fear Center

Palm of hand (Brain Stem), controls heart, Lungs, etc.

Seigel, D (2015). Brainstorm: The Power & Purpose of the Teenage Brain. New York, NY: Penguin

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Fear Cascade

Flock:

Flee:

Fight:

Freeze:

Faint/ Submit

Flock: gangs, violent or hurtful relationships, suicide attempts, addiction, self-injury

Flee: running away, hiding, suicide attempts, addiction, self-injuryFight: all forms of aggression, suicide attempts, addiction, self-injury Freeze: depression, being stuck, Not protecting children, looks oppositional, addiction, self-injury

Faint (Submit): Protecting perpetrators, Curling into a fetal position, Flopping, addiction, self-injury

Flock: Safe relationships, clubs, church, teams, volunteerism

Flee: Leaving a problematic job or relationship

Fight: Assertiveness, Exercise, sports, danceYoga, yardwork, walks can connect action & stillness.

Freeze: Quiet time, studying, school, gardening

Faint/Submit: prayer, meditation, Breathing.

Please don’t ask someone to risk their life to get

connection.

© 2016 Finding Hope Consulting LLC© 2020 Artwork: Chelsey Getz

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Unsafe Safe

Flock

Flee

Fight

Freeze

Faint/ Submit

The Fear Cascade for

Students

© 2016 Mary Vicario, Finding Hope Consulting, LLC www.findinghopecosulting.com

Artwork © 2020 Karen Boyhen

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http://www.findinghopecosulting.com/

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Types of Thought: How We Make Sense of & Experience Our World

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Pre-operational ThoughtModerate IDD Ages (2-7)

“Egocentric” Cannot put causation of an event outside of one’s self. “If it happens to me, I caused it.” Often creates characters to express & work with feelings & thoughts. Thoughts are experienced (felt) as bodily sensations that they do not have words to comprehend or describe.

Concrete Operational Thought Mild IDD(Ages 7-12)

Interacts & makes sense of the world by acting on it. Thoughts can be experienced as visual & auditory experiences inside their head.

Formal Operational Thought No IDD(12- adulthood)

Interacts & makes sense of the world by thinkingabout it using language.

Types of Thought and Intellectual & Developmental Disabilities (IDD)

Gentile, J., & Gillig, P. (Eds.). (2012). Psychiatry of intellectual disability: A practical manual. Oxford: Wiley-Blackwell. 10

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Pre-operational ThoughtModerate IDD

May be able focus on parts but cannot see that they come together to make a whole

Pre-operational ThoughtModerate IDD

May be able to differentiate parts from wholes but cannot integrate

Concrete Operational Thought Mild IDD

May be able to see and integrate both parts and wholes, but cannot use abstractions, such as language, to demonstrate what they understand



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Centration Pre-operational Thought

Mild IDD (& Trauma)

To center attention on a single feature of a person, object or situation. (All or nothing thinking)

Static FocusPre-operational Thought

Moderate IDD

Focused on the here and now and cannot comprehend the in between steps needed to move from one state of being to another. (basketball vs. baseball)


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• Irreversible Thinking (Pre-operational Thought - Moderate IDD): The inability to conceive the possibility that anything may return to a previous state. “It’s okay, he’s nice to me now.”

• Transduction (Pre-operational Thought - Moderate IDD):Events that occur together are connected (Mom turning on the light

when Dad comes home = turning on the light brings Dad home)

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Gentile, J., & Gillig, P. (Eds.). (2012). Psychiatry of intellectual disability: A practical manual. Oxford: Wiley-Blackwell.

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Types of Thought and Intellectual & Developmental Disabilities

(IDD)

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Gentile, J., & Gillig, P. (Eds.). (2012). Psychiatry of intellectual disability: A practical manual. Oxford: Wiley-Blackwell.

Centric World View (Pre-operational Thought Moderate IDD): The inability to put causation of an event outside of themselves. “If it happens to me, I caused it.”

Inability to use abstractions (Concrete Operational Thought Mild IDD): Language is an abstraction which makes talk therapy contraindicated for people in pre-operational thought.

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Objective 2:

Participants will be able to identify and address the needs and drives behind “The Five Purposes of Behavior.”

Our Greatest Need & Our Greatest Fear:

The Biological Drives Behind “The Five Purposes of Behavior” and

Ways to Meet Them.

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Reptiles…hatch their young then they quickly scurry away.

Humans… are dependent on relational connection for:

● Access to resources

● Life –beliefs are developed through early relationships

● Developmental milestones

● Brain developmentare embedded in relational experiences

17©2020 Mary Vicario Finding Hope Consulting LLCwww.Findinghopeconsulting.com

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Connection is our greatest need and

Disconnection is our greatest fearAmy Banks, MD

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Speaking of Attention…

Why do people need so much of it?

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Human Brain Development and Relationships

Humans are the only mammals for whom: ● The whites of the eyes are clearly visible● 50%- 70% of brain development occurs after

birth. ○ Wang, Kate (2012) & (Experience-Dependent Maturation of Neuronal

Systems) Putnam, Frank (2004)

● Synaptogenesis: The birth of the connectors (synapses) that are needed for brain development increases dramatically after birth and are dependent upon environment-stimulated activity


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NEURONS SOCIALIZING!

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The Social Neuron(COZOLINO, 2006)

“Neurons are by their nature, social; they shun isolation and depend on their neighbors for their for survival. If they are not sending and receiving messages from other neurons on a constant basis, they literally shrink and die.”

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Reflect, Honor, Connect

• back with compassion what you heard them say.

Reflect

• Thank them for sharing

Honor

• Them with safety & supports. • Ask: How can I help you feel safe?• Or whatever you wanted to say originally…keep it for the Connect

Connect

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“We did then what we knew to do, and now that we know better,

we do better.”

~Maya Angelou

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When…

©2020 Mary Vicario Finding Hope Consulting LLCwww.Findinghopeconsulting.com

I am… I need… Feeling Unnoticed and unimportant and I am attention seeking…

Positive Attention like a job, task or way to help someone or in some way

Feeling vulnerable & hiding it behind agitation and bullying…

Limits connected with safety.

Feeling lost & risk taking… Physical activity & sensory integration (rhythmic movement)

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The Neurobiological Purpose of Behavior

The Five Reasons for BehaviorThe Neurological Need Driving the Behavior: (Burke, 2014)

1. Attention To feel connected, accepted & loved

2. Escape To feel safe & secure

3. Tangibles To have some say in your life

4. Bored To have a purpose in life

5. Pain To feel less isolated or trapped


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Communicate AlternativelyExpress the feelings in a nonverbal way – show your feelings, through ... painting, movement,

music, writing... (10 minutes)

Release EndorphinsMove or laugh to elevate mood and lift you up emotionally– watch funny videos, dance, do yoga, Thai Chi, try to skip & frown at the same time (I bet you can't do it), jump rope, jog or

walk, (even in place is fine), bounce on a mini trampoline. (10 minutes)

Self SootheDo some sensory comfort activities – run hands under warm water, use sugar scrub, light a

scented candle and enjoy the aroma, work with comforting textures, stroke a pet (10minutes)

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CARESS: Replacing Self Injury with Self Soothing

Ferentz,L.(2015).Lettinggoofself-destructivebehaviors:Aworkbookofhopeandhealing.Routledge,NewYork,NY.

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Objective 3:

Participants will be able to identify and address the hidden resilience in commonly learned survival strategies like lying, stealing, manipulating, aggression & defiance

What Works One Place, May Not Work in Another:

The hidden resilience found incommonly learned survival strategies

and how to use that resilience toaddress them.

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To understand behavior never remove a person from their context.

- Maureen Walker, Ph.D.

30Walker,M.&Rosen,W.(Eds.)(2004).Howconnectionsheal:StoriesfromRelational-CulturalTherapy.NewYork,NY:TheGuilfordPress.

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1. Manipulating2. Lying3. Stealing4. Hording5. Aggression6. Defiance/”Button Pushing”7. Poor Eye Contact

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Biologically Based Fear Responses(Forbes & Post, 2007)

8. Food issues• Gorging• Starving • Purging

9. Sleep issues

10. Enuresis

11. Encopresis

12. Self harm


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Irritation Equals Fear – Even in Us. (Forbes & Post, 2007)

All behavior is purposeful (Sigmund Freud)

Challenging behavior is the language of a person who has lost their voice. (Karyn Purvis)

Everything an abused person does after the abuse is designed to give them a sense of safety (Gil, 1991)

Connect Limits with safety (Use the Safety Script)

The one whose amygdala is calm wins! (Forbes & Post, 2007)

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The Top 5 Things to Remember When Addressing Biologically Based Fear Responses


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The Anger Onion: A Tool for Understanding

In the brain…

Irritation =Threat

(Forbes & Post, 2007)

When you see anger, aggression, risk taking & self-injurious behavior…

Think sadness & then use it as bridge to identify the fear.

Anger

Sadness/ Discomfort

Fear/ Worry/ Shame

©2020 Mary Vicario Finding Hope Consulting LLCwww.Findinghopeconsulting.com 33

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Using the Love Onion to Help Peel the Anger Onion

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Empathy

Connection

Jennifer McKenzie © 2017

Curiosity Anger

Sadness/ Discomfort

Fear/ Worry/ Shame


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When we let go of judging and approach with curiosity the anger or angry behaviors,This allows us to feel empathy for the person struggling with their anger.

When we reflect what we see without judgment, the person feels safe enough to share their sadness.

When we reflect the sadness, we both experience empathyEmpathy allows the person to feel safe enough to share their fear

Shared fear allows us to connect, and problem solve how to address the (fear that is driving the anger).

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Using the Love Onion to Help Peel the Anger Onion


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Trauma Triangle

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Victim

PersecutorRescuer

Bloom, 2010

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Turning the Trauma Triangle into the Empowerment Triangle

Inviter/Challenger

Creator

Coach

Persecutor

Victim

Rescuer

Bloom, 2010 37

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Where it comes from & Hidden Resilience:

What we can do about it:

Manipulating: is learned when you have not been able to safely ask directly for what you need. Hidden Resilience: Resourcefulness

Help the person:1. Distinguish wants from needs 2. Identify safe people they can ask directly for their needs 3. Use the 3 Ps to practice ways to directly ask for what they need.

Lying is learned when reality is not allowed to be real, so the truth becomes what you need it to be to get the job done. Hidden Resilience: Determination & Creativity

Help them to identify what they are trying to accomplish and ways to directly accomplish their goal.

Stealing is a drive to get dopamine when nurturance & other basic needs were missing. Hidden Resilience: Strategy

Use a body mandala to show what it feels like in their body when they steal. Help them find other ways to get that same feeling.


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Hoarding is a way to hold on to things as a replacement for basic needs, especially safety & nurturance.Hidden Resilience: Comfort, Nurturing & Caring

1. Have them tell you the story of what is important about what they are saving. 2. Reflect, Honor & Connect3. Help them find other ways to get those feelings.

Aggression is a tool used when a person feels unsafe.Hidden Resilience: Action & A Drive for Justice

1. Connect rules with safety2. Increase communications skills especially non-verbal ones3. Use the Safety Script to connect before you correct4. Use an anger onion to identify the fear & then address the fear.


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Defiance is a way to regain a feeling of control (which is needed for a sense of safety) when voice and choice have been lost.Hidden Resilience: The Courage to Challenge Power Over

Remember, they cannot say, “yes” until they are allowed to say, “No.”

“Button Pushing” is a way to keep neurons in the brain from dying off, which happens when we are being ignored. Our brain will drive us to seek negative attention rather than settle for no attention at all. Hidden Resilience: Observant, Determined & Creative

Help them find positive ways to connect and descriptively highlight how their actions help others or the greater good.

Poor Eye Contact is a sign of overstimulation.Hidden Resilience: Protective

Do side by side activities.


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For all food issues, no matter what the cause, allow them to see where food is, have access to food that cannot hurt them if they overeat, like carrot, apples or celery.

Where it comes from: What we can do about it:

Gorging & purging most often comes from food insecurity. Gorging without purging can also come from unrecognized sexual assault & is a way to protect oneself. Hidden Resilience: Focus & Comfort

Help them feel safe and engage in mindful eating. DO NOT do this for anorexia. It could bring on flashbacks & make it worse.

Anorexia often (but not always) comes from unrecognized oral sexual assault. Hidden Resilience: Focus and Determination

Use the person in the mandala to find out their safe feeling & have things that evoke that safe feeling around when they are eating.


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Forbes, H., & Post, B. (2006). Beyond consequences, logic, and control: A love-based approach to helping attachment-challenged children with severe behaviors. Orlando, FL: Beyond Consequences Institute.

Where it comes from: What we can do about it:

Sleep Issues come from frightening experiences that happened at night.

Use rainbow dots, discuss successes from the day, help them plan what they want to dream about.

Enuresis (wetting), Encopresis (soiling) & vomiting These Are BRAINSTEM FEAR RESPONSES. It is NEVER a choice.

1. Notice when it happens & help them gain actual & felt safety from what is triggering it. 2. Use an Anger Onion to identify the fear if needed. 3. DO NOT punish or shame it. That will only intensify it.


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Interventions for Morning IssuesWaking Up with Diana Ross 1. Before bed decide with the individual on

a wake-up song. It can be one you make up together or one that you both know.

2. In the morning open the blinds and let some light in for 5 – 10 minutes.

3. Return to the room and start singing the wake-up song.

4. Sit by the side of the bed until the individual starts singing the wake-up song with you.


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Artwork by: Raychelle DuazoVia: Amplifier.org45

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Documents

Taking the Duel out of Dual DiagnosisWV2021