Theory Into Practice: Interventions for complex needs Dr Tricia Skuse Clinical Psychologist All...

Theory Into Practice: Interventions for complex

needsDr Tricia Skuse

Clinical PsychologistAll Wales Forensic Adolescent Consultation and

Treatment Service (FACTS)

[email protected]

Characteristics of young offenders• Cognitive immaturity – many not yet have reached formal operational

thought. Therefore struggle with:– Consequential thinking– Manipulating concepts simultaneously– Identifying inconsistencies in arguments– Understanding the impact of situational factors– Reframing problems– Creating solutions– Tolerate uncertainty

• Attachment difficulties – high incidence

• Trauma - high incidence

• Learning DisabilityEst. two thirds of young offenders have LD or borderline LD

– global delay– brain injury – result of attachment or trauma difficulties

• Mental health difficulties

• Substance misuse…complex families…bereavement…/…

Impact of trauma and attachment problems

• Deficiencies in…

– Executive functioning (attention, concentration, anticipation, planning, abstract reasoning, cognitive flexibility, impulse control)

– Verbal IQ– Verbal memory– Expressive and receptive language skills

• These in turn impact on cognitive functioning and the ability to use support, as well as affecting mental health.

Significant implications for how to work and intervene with young people with histories of trauma and poor attachment to caregivers.

Conventional offender treatment programmes

Typical examples…

– Anger Management– Victim empathy

Such approaches are premised on the notion that clients can think through and verbally express and analyse their experiences with another individual.

Require ability to analyse, explain, reframe and regulate difficult or new feelings.

Not that the young people are beyond help, we just need a model of working that achieves the following:

• Takes account of the complexity of their lives and their developmental progress so far

• Is relational in its focus – development of trust/secure base

• Allows neural connections to be made – impacts upon Internal Working Model

• Works with plasticity of the brain and natural maturation

How best to intervene?

Interventions for complex needs?

• Recognition that this sub-population is intrinsically different and may require different way of assessing and intervening

• Psychological formulation of cases– Process of making sense of person’s difficulties in context of

• Their relationships• Social circumstances focus on causes not symptoms • Life events• The sense they have made of them

– Different from psychiatric diagnosis which often says little about the individual, and the context and impact of difficulties

• Intervention that is for the long term rather than quick fix

• Intervention that is sequenced

Sequencing…

• Increasing evidence that interventions need to replicate the normal sequential process of development so that the child can ‘re-approximate a more normal developmental trajectory’.

(Perry & Hambrick, 2008)

Theory into Practice: The Trauma Recovery Model

• TRM: is a composite model of theory and practice…

• That draws on…

– Maslow’s Hierarchy of Needs– Cognitive theory of child/adolescent development– Attachment theory– Current understanding of neuro-development– Criminology: Desistance theory, Good Lives and

change theories

…as they apply to adolescents with complex histories of trauma and maltreatment

FOUNDATIONAL BELIEF - REDEEMABILITY

INSTABILITY / CHAOTIC・ Challenging behaviour (aggression, absconding, self-harm Chaotic lifestyle Drug use ・ Poor sleep / hygiene Offending Poor nutrition Inappropriate relationships Over-reliance on peers

TRUST / RELATIONSHIP BUILDING Smiling more Building closer relationships with 1 or 2 staff

Increased willingness to comply with routines Ongoing peer relationship difficulties Ongoing confrontational / challenging

outbursts

WORKING THROUGH TRAUMA Return to difficult behaviours as trauma is processed Clingy with staff / rejecting of staff

INSIGHT / AWARENESS Calmer Increased insight into behaviour More balanced self-

narrative

FUTURE PLANNING: Increased self-belief /

esteem Acceptance of abilities /

potential

ConfidenceAchieving

goalsIndepende

nce

COGNITIVE READINESS

DISCLOSURE

READINESS TO BUILD RELATIONSHIPS WITH ADULTS

NEEDLAYERS OF INTERVENTION

PRESENTATION / BEHAVIOUR

Regular meals / bedtimes School Clear boundaries

Maximum 1:1 times with adults Clear boundaries Maintenance of structure / routine

Specialist therapeutic intervention re: trauma Containment Co-regulation Interactive repair Bereavement counselling

Cognitive interventions e.g. anger management, consequential thinking

Guided goal-setting Targets Scaffolded structure Support into education / training placement Help to structure free time constructively Motivational interviewing

Provide a supportive safety net for learning

Need for structure and

routine in everyday life

Need to develop trusting relationships

with appropriate adults Need to develop a

secure base

Processing past experiences Grieving

losses

Adult guided and supported planning Sense of purpose &

achievement – structured to maximise the chances of success

Integration of old & new self

Autonomy within the supported context Increased self-determination

TRAUMA RECOVERY MODELSkuse & Matthew

Key Features: Emphasis on relationship with the young person

• Interactive Repair is the process of quickly repairing the relationship with a young person after s/he has been disciplined. Reassure relationship is intact Reduce anxiety Behaviour doesn’t escalate Consequences for behaviour remain

• Overall aim is to help the individual to successfully connect-break-reconnect, and to give the child experiences of attuned and responsive parenting that they missed.

Key features: Disclosure Threshold

• Indirect acknowledgement of trauma (e.g. via music, lyric writing, drawing, etc.)

• Testing of safety boundaries – “can I trust you?” Rejecting people to see if they’ll still be there. Can you bear what I have to tell you?...

• Direct acknowledgement of trauma

• Impact of increased level of disclosures– On YP– On other agencies– On YOS staff





outbursts



narrative



potential

ConfidenceAchieving

goalsIndepende

nce

COGNITIVE READINESS

DISCLOSURE














secure base


losses






Key features: Cognitive Readiness Threshold

• It is some time before conventional cognitive interventions can usefully be applied





outbursts



narrative



potential

ConfidenceAchieving

goalsIndepende

nce

COGNITIVE READINESS

DISCLOSURE














secure base


losses






Key features: Upper levels of TRM

• Scaffolded support …moving on to…

• …Safety net of support from people or an organisation that has known them for a long time

• Both more akin to ‘normal’ responsive parenting

Interventions for complex needs• Psychological approach

• Emphasis is on relationships and providing what young people have often missed in early childhood

• Tailored to the individual – case formulation

• Sequenced according to need

• Strengths based – building on existing interests and skills

• Applied and ‘hands on’

[email protected]

Theory Into Practice: Interventions for complex needs Dr Tricia Skuse Clinical Psychologist All...

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