Positive Approaches Journal, Volume 8, Issue 2

Cherundolo | 7-13

Being Misunderstood

Daniel has a long history of state hospital and residential placements beginning at the age of 15, when he was diagnosed with Depression, Bipolar Disorder, and Intermittent Explosive Disorder. He had various mental health services in place throughout his childhood starting at age 9. This included outpatient therapy and in-home behavioral health services. In-home services include therapy and therapeutic support to assist parents with learning how to manage difficult behaviors.  As he got older, he received services through Assertive Community Treatment Program (ACT), partial hospitalization programs, and various stays in residential treatment facilities. ACT assisted him with medication management and learning various independent living skills. Daniel was given the opportunity to move into his own apartment at age 20 after a long stay in a residential facility. In a short time, he was evicted for setting small fires outside and damaging property resulting, unfortunately, in being admitted to a psychiatric inpatient setting. At this time, he reported feeling suicidal and depressed. Various mental health residential rehabilitation placements refused to support him due to his previous fire-setting behaviors, and his parents did not want him back in the home due to alleged sexually inappropriate behaviors toward his younger sister when he had lived at home. This downward spiral of lack of appropriate supports, misconceptions, and lack of understanding, led to an admission to a state hospital for psychiatric treatment when Daniel was just 20 years old.

During his stay at the state hospital, Daniel actively participated in various therapeutic and social groups. He learned how to complete chores such as laundry and cleaning his room. He had a job in the hospital, where he was able to earn money by completing clerical tasks. Daniel was excited about these opportunities as he knew he was taking steps toward his own independence.  Generally, Daniel struggled with maintaining friendships and intimate relationships that he expressed as important to him. He identified as being bisexual and stated that his parents have never accepted this about him. Beyond consensual, casual sexual relations with peers at the hospital, there were not many positive peer relationships, although Daniel reported later that he was engaged to another man at the hospital. Other than his interest in romantic and intimate relationships, Daniel reportedly liked to keep to himself. He was unsure how to pursue platonic friendships, even when others tried to be friendly.  Daniel often engaged with others on Facebook, but this seemed to be used more as a way of connecting with the broader LGBT culture (individuals who identify as Lesbian, Gay, Bisexual, and Transgender) than making friends.

While at the state hospital, Daniel was diagnosed with autism by the psychiatrist. This new perspective and additional insight provided by Daniel regarding the fire-setting behaviors prompted a different approach to understanding him. Specifically, when asked, Daniel would say that he would set fires because he not only liked the smell but being outside next to a fire helped him feel calm and content. It helped him from feeling over-stimulated.  It was determined by staff at the hospital that Daniel did not engage in this activity to be destructive. To that end, additional evaluations were conducted by consultants. Although there were some discrepant clinical impressions, there was confirmation by the state hospital’s psychiatrist that since there was no recent history of physical aggression, fire setting, or self-injurious behavior, along with improvement in provocative language and threats to harm self or others, Daniel was recommended for discharge to a placement in the community with 24/7 supervision after living in the state hospital for a little over four years.

Although Daniel was recommended for discharge, it was difficult to find a place for him due to his fire-setting reputation, despite evaluations that provided information for service planning for his transition into the community. Fortunately, the state hospital social worker assisted Daniel to apply for a Medicaid waiver and after navigating all the red tape, enrollment proceeded and a team was built starting with a supports coordination agency that was not just willing but experienced in supporting people with autism. A supports coordinator (SC) assists with linking individuals to needed services to address their diagnostic and independent living needs. In this case, a residential living situation was needed so Daniel could be discharged from the hospital.  Daniel’s SC visited with him in the hospital and participated in further discharge planning to get an understanding of Daniel’s needs to be successful in the community. Although the SC found that there were providers who were either not receptive or who did not have a home available with 24-hour support, the SC was able to find a provider who was willing to support Daniel. Despite having a preference to live in a county closer to where his parents lived, Daniel and his family agreed to try out a new home that was in another county once the options were shared and discussed as a team. After visiting the available apartment, Daniel became excited about living in his own apartment, and he was anxious to meet his new housemates and explore the local community.

Growing Toward Independence

Although Daniel was recommended for discharge, it was difficult to find a place for him due to his fire-setting reputation, despite evaluations that provided information for service planning for his transition into the community. Fortunately, the state hospital social worker assisted Daniel to apply for a Medicaid waiver and after navigating all the red tape, enrollment proceeded and a team was built starting with a supports coordination agency that was not just willing but experienced in supporting people with autism. A supports coordinator (SC) assists with linking individuals to needed services to address their diagnostic and independent living needs. In this case, a residential living situation was needed so Daniel could be discharged from the hospital.  Daniel’s SC visited with him in the hospital and participated in further discharge planning to get an understanding of Daniel’s needs to be successful in the community. Although the SC found that there were providers who were either not receptive or who did not have a home available with 24-hour support, the SC was able to find a provider who was willing to support Daniel. Despite having a preference to live in a county closer to where his parents lived, Daniel and his family agreed to try out a new home that was in another county once the options were shared and discussed as a team. After visiting the available apartment, Daniel became excited about living in his own apartment, and he was anxious to meet his new housemates and explore the local community.

After intake and assessments, Daniel and his team determined that community support and behavioral support services would be an effective complement to the residential 1:1 supervision as the community team learned more about Daniel’s strengths and needs. Community Support provides assistance with finding social activities in the community and supporting the individual during these activities. Behavior Support consists of assisting the individual with managing negative behaviors and practicing positive coping skills for difficulty situations. Fortunately, Daniel was also assigned a mental health Blended Case Manager, who was able to link Daniel to mental health services and provide more frequent support than the SC. Daniel quickly developed a positive relationship with his staff. Daniel has reported that he most enjoys getting out in the community and doing the things that he likes to do like attending Gay Pride events, attending dances, and going out shopping and to lunch with peers. He likes to tell jokes and make his peers and staff members laugh. Daniel was also interested in applying for jobs so he could earn his own money and exploring volunteering or working at a plant nursery or outdoor garden as he enjoys nature and being outside.

With the support of his team, Daniel learned how to manage his own groceries and cook small meals for himself. He learned to keep his room clean and perform laundry duties. Daniel takes his medication daily with the assistance of staff. He has started to learn about the medications he is prescribed and the intended results. He has recently started to learn how to use Uber and the bus system in the area to assist him with transportation needs. He has plans to visit a friend a few hours away and will need transportation. He does not feel comfortable getting his driver’s license at this time due to feeling overwhelmed about driving.

Challenges

Despite a generally positive transition, supporting Daniel has been a work in progress with this team. Daniel had to adjust to living with three other housemates in a two-bedroom apartment. His first housemate moved out due to his own personal behavioral issues, and there are often changes with who lives in the apartment depending on individual needs. Some of these housemates are at a higher level of care than Daniel, so he often does not feel a connection with them. He would rather find a community of LGBT friends he finds relatable. With the help of staff, he has been able to learn to communicate with housemates when he needs his own space instead of becoming angry and verbally “lashing out.”  When Daniel gets frustrated, he finds it helpful to go for a walk with staff or go out in the community to a Wawa to keep himself calm. He did not have the ability to engage in these calming strategies while he was in the state hospital. He has come up with a list of coping skills and calming activities that he can use to manage his anxiety and/or frustration. He keeps this list on the wall next to the TV in the living room.

One of the areas of independent living that Daniel struggles with the most is budgeting and money management. He enjoys spending money and online shopping, where he will often splurge on unnecessary items that he will buy impulsively. This then leads to a lack of money for groceries and other spending money.  When he was in the state hospital, his income was limited and all of his needs were provided for, so he did not have as much freedom to buy the things he wanted. Now that things are different, Daniel has to understand how managing money and controlling spending is an important part of learning to live independently. His team works with him daily on this goal and has created a worksheet for him so he can write down his needs and wants with the amount of money he has. This helps him see how much money he can spend. Daniel believes that he can live with a friend who may have his own place and that he will not have to pay rent. He does not want to think about potential utility bills, food costs, tuition for school, and transportation needs. He is very adamant that he can live on his own, yet shuts down when financial issues are brought up.

Another area that is a struggle for Daniel is navigating intimate relationships. Daniel wants to be in a romantic relationship and to get married. He seems to want this to happen very quickly, without taking the steps to get to know someone. Daniel meets people and explores relationships by connecting with others on Facebook and in the apartment complex where he lives. He dated a male who lives in another group home in the complex, although they have since decided to remain friends. He also interacts with peers during community outings.  Daniel’s team supports his desire to find intimacy and encourages him to meet people and explore relationships slowly, so he can be successful. This is often a difficult concept for Daniel, and causes much anxiety for him, as he had a fiancé when he was at the state hospital, and he states that he wants to be able to meet his own sexual needs.  Daniel talks about being undecided and conflicted between wanting a serious relationship and wanted to explore new ones. When Daniel was in the hospital, he often got caught up in romantic relationships with other men. He is now learning to understand the difference between sexual intimacy and emotional intimacy with partners. His behavioral specialist is open to discussing his sexuality and talks with him about how sex can be different from other types of intimacy.

Keys to Success

Daniel has been successful in many ways over the last two years. He secured a job at Burger King and successfully worked there for approximately six months with the assistance of a job coach. He decided to leave because he wanted to pursue his passion of obtaining a criminal justice degree. Daniel applied and was accepted at a local community college. This was a big victory for Daniel, as he never graduated high school. With the help of disability services at the college, he will be able to take remedial classes, and is planning to take classes in Criminal Justice. However, he has since decided to delay community college and focus on independent living skills and relationship building with his new boyfriend, Doug.  Daniel is still learning to process concerns before making impulsive decisions. He feels that working a few days at an outdoor nursery may be more suited to him at this time than a fast food restaurant. He is working on having a more positive relationship with family members and being able to express his sexuality in positive ways. Daniel has agreed to start participating in more social groups and community activities. There continues to be team collaboration (team meetings, conference calls) to address any issues or concerns that arise.