Rafael Rabenstein

rafael@rabenstein.net

Nearly one-third of people with mental illness have more than one diagnosis (Wittchen et al., 2011; Jacobi et al., 2014, 2015). It can therefore be assumed that a purely disorder-specific approach might have insufficient success. This chapter presents therapeutic approaches and considerations for working with people who have multiple diagnoses, complex and chronic disease trajectories. In addition to a disorder-specific approach, transdiagnostic considerations play more of a role here. Our approach here offers a hirarchical approach. Depending on the psychosocial level of functioning, possible interventions will be outlined and treatment strategies Fig. VI.11.1. be presented

In this context, the ICF – International Classification of Functioning, Disability and Health of the WHO should be referred to (Fig.: VI.11.2.) The focus of this classification is to enable people to actively shape their lives and participate in social life. And this is independent of physical or more psychological impairments, which are to be alleviated or eliminated, but are not the only (success) criterion. Social and occupational participation and an opportunity to actively pursue this are essential overarching goals of any therapy. This is done in the sense of “self-management” and “empowerment”, i.e. the empowerment to successfully implement one’s own goals. It is important to consider the socio-cultural context and to pursue these goals in a socially responsible manner.

Fig. VI.11.2: ICF – International Classification of Functioning, Disability and Health (WHO)

This approach is used primarily in the rehabilitation of people with mental illness. Thus, cross-interference goals are defined. There are also questionnaires that can be used as follow-up diagnostics (e.g. Mini ICF-P; Linden et al., 2005).

Fig. VI.11.1. Hierarchical, cross-disorder treatment strategies.

Stage 1: supportive and sustaining conversations

The lowest or most basal level is the accompaniment and support of patients. Especially in crises and extreme situations, interventions that support the patient are in focus. The focus of the conversation here is validating conversation. In addition, the therapist is challenged in the sense of “case management”. This may be in organizing an outpatient visit or inpatient admission. But so are counseling centers and other psychosocial interventions. Patients from social psychiatric settings, in particular, often require basal interventions. This is of course not psychotherapy in the strict sense, but can be a component of therapy, especially in crises.

Stage 2: basic behavioral therapy interventions.

Stage 2 interventions are also useful for stabilizing and improving psychosocial functioning levels. This starts with planning a day’s structure, teaching coping strategies such as DBT skills, simple cognitive interventions such as reality checks. If the goal of level one is crisis management, the goal of level two is everyday life management.

Psychoeducational elements are also a key component of this phase/stage.

Stage 3: Mindfulness and acceptance

A seamless transition from Level 2 to Level 3 is provided by mindfulness-based interventions on the one hand, and acceptance-focused approaches on the other. Mindfulness is applicable in the sense of a coping strategy for all problems and symptoms that burden the patient. In particular, obsessive thoughts, ruminations, fears, catastrophizing, and the like. But emotional states can also be regulated with the help of mindfulness. This approach of unaware perception promotes the acceptance of emotionally stressful situations. Other acceptance-based interventions are designed to help affected individuals cope better with chronic or distressing conditions.

Stage 4: Cognitive interventions

Cognitive interventions, as cross-disorder and transdiagnostic approaches, are not antithetical to Level 3, but provide another approach to distressing thoughts and beliefs. However, breaking through strategies such as “jumping to conclusions” and a reality check as a basic strategy are especially important here, along with improving self-awareness. Depending on the cognitive skills and the “mentalizing ability”, all cognitive interventions can be brought in. Experience has shown that there are large differences in practicality.

Stage 5: disorder-specific and evidence-based behavioral therapy.

If patients have a sufficiently high level of functioning and an unchronicled Axis I disorder, the first place to start is, of course, in disorder-specific approaches. This does not exclude the previous stages, but each patient should be offered a disorder-specific approach as a means of choice; only if this approach is too early, due to a crisis or a restriction in the psychosocial level of functioning, should the underlying stages be integrated as cross-disorder basic interventions.

Stage 6: emotion-focused interventions

If patients have received adequate cross-disorder or disorder-specific treatment and do not improve, consideration should be given to integrating emotion-focused, transdiagnostic approaches. Trauma should only be considered in this context when disorder-specific, evidence-based treatment was/is not effective. However, this may equally mean that trauma therapy per se is not possible and psychosocial support and stabilization are more indicated. It is not always possible for affected persons to perform trauma exposure (e.g.: chronic psychoses, “harm reduction” approach, etc.).

Literature:

Jacobi F, Höfler M, Strehle J et al (2014) Mental disorders in the general population: study on the health of adults in Germany and its supplementary module Mental Health (DEGS1-MH). The Neurologist 85:77-87.

Jacobi F, Höfler M, Strehle J et al (2015) Twelve-months prevalence of mental disorders in the German Health Interview and Examination Survey for Adults – Mental Health Module (DEGS1-MH): a methodological addendum and correction. Int J Methods Psychiatr Res.

Linden, M., Baron, S., (2005). The “Mini-ICF Rating for Mental Disorders (Mini-ICF-P).” A brief instrument for assessing ability disorders in mental illness. The Rehabilitation Volume 44 (pp.144-151). Vienna: Springer

World Health Organization- WHO (2001): International Classification of Functioning, Disability and Health: Short Version: ICF. Geneva, WHO

Wittchen HU, Jacobi F, Rehm J et al (2011) The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 21:655-679.