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HighRisk–HighHarm-HighVulnerability:
Workingwithyoungpeoplewhodisplayhighriskbehaviour
DrAndrewRogersConsultantClinical&[email protected]
HealthWarning
• ThefirstprincipleofsupporFngothersisthatyouneedtocareforyourselffirst!
• LOOKAFTERYOURSELVES
“Itisimpossibletounderstandthepeoplewebecomeunlessweunderstandthechildrenwe
havebeen”
TheScaleoftheProblem
ReflecFons&observaFons
• Experienceacross3systems:SocialCare/MentalHealth/CriminalJusFceSystem
• CommunityCAMHS/YOT/LACResidenFal/Courts/Securewelfare/InpaFentMH/Prison(LASCH,SCH,YOI)
• Sameclientgroup,butdifferent‘treatment’systems?
• Coregroup-complexhistoriesofsurvival,aaachmentdisrupFonandtrauma
• Presentwithhighriskbehaviours(tothemselvesand/orothers)
• Challengewholesystems–YPgetpassedbetweenandwithin
SecngtheScene-someobservaFons
• Mentalhealthservicesodenoperateattheperiphery(DNA/untreatable/’behavioural’)
• Majoritydonotpresentwithone‘label’:– Offender/VicFm/Dangerous/Vulnerable/Arsonist/Violent/’Self-harmer’– CD/ADHD/PTSD/ASD/LD/ATTACHMENTD/BPD/ASPD/&?PSYCHOSIS!!
• DifficulFes‘(re)-emerge’,intensify(higherrisk)andbecomeless‘tolerated’inadolescence(yr9!!)
• But…..odenidenFfiableearlier• Highlyresourceintensive,difficulttochange,frustraFngly
similaroutcomes• PrognosispoorandhighlylikelytransiFontoadultMH/
criminaljusFce/forensicservices
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ReflecFons-PrimarydifficulFes• Categorically/DiagnosFcallydriven–toosimplisFc• IntervenFonsarealltoooden‘prescribed’,singlemodalitydriven(e.g.
CBT,medicaFon,‘offence-focussed’)• IntervenFonsodendeliveredtotheindividualwithoutaddressingthe
systemiccontext• Adult-driven:LackofdevelopmentalperspecFve–‘childrenarenotmini-
adults’• Confused,chaoAcresponses:“Differentsystems,governedbydifferentprinciples,fundeddifferentlyandwithdifferentaims,arealltryingtosupportyoungpeopleinaco-ordinatedmanner”Rogersetal.(2015)• Lackofco-ordinaFonandunderpinningtherapeuFcraFonaleacross
systemsofcare
UNDERSTANDINGTHEPROBLEM
ChangingthefundamentalquesFon:
It’snotwhatis‘wrong’withyou?
It’swhathashappenedtoyou? Foderaro, 1991
MulFple&developmentalperspecFves
• EvoluAon&Survival• Childdevelopment• Braindevelopment/Neuroscience• AUachment• Trauma• Systemic• Biology,geneFcsandepigeneFcs• Behavioural• CogniFve• Psychodynamic• Criminonology/Sociology/Desistance/Delinquency• KeyisintegraAngtheoriesandoperaAonalisingintopracAce....
BrainDevelopment
Thinking (higher) Brain
Emotional Brain
Old (‘reptilian’) Brain
KeyAmesforbraindevelopment:• 0-2years• ADOLESCENCE• ConAnuousdevelopmentwellinto20’s
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KeyassumpFons• Wearebornveryunfinished-toadaptandsurvive
• EarlycaregivingrelaFonshipsandtheimpactofwiderexperiences[includingtrauma]‘sculpt’thebrain
• Ourgenesinteractwithourenvironment/experiences‘invivo’
• BraindevelopmentconFnueswellintoadulthood(25+)
ATTACHMENT
Whatisaaachment?• AaachmentisanadapEveevoluFonaryprocessandameansofsurvival
• Involvesseekingproximity[througha7achmentbehaviour]totheprimarycaregiverwhenachildexperiencesdistress/discomfort/need
• Theresponseofthecaregiverhelpsthechilddevelopamental‘model’ofthemselves,othersandtheworld(relaAonships)
“Boththequalityofcareandsecurityofaaachmentaffectchildren’slatercapacityofempathy,emoFonalregulaFon,cogniFvedevelopmentandbehaviouralcontrol”(Kestenbaumetal,1989)
Developmentalprocess
Dysregulated Co-regulated Self-regulated
– UnderstandingownandothersbehaviourandemoFonalexperience(e.g.asenseofempathy)
– Understandingownworthiness(e.g.selfesteem)
– RecognisingemoFonalavailabilityofothersandtheirabilitytoprovidea‘safe’environment(i.e.theabilitytoaskforhelp)
– TheabilitytorecogniseandregulateemoAon
– Socialandmoraldevelopment
AaachmentisfoundaFonof:
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Aaachment&Offending• Insecureaaachmentclearlylinkedtooffendingbehaviour(Fonagyetal,1996)
• 40adultmale‘seriousoffenders’:95%ofhadinsecureaaachment,53%A/C(vanIjzendoornetal,1997)
• 24‘psychopathic’offendershadhighratesofdismissing(avoidant)aaachmentstyleanddisorganised(unresolved).RelatedtorejecFngfathersandidealisedmothers.(Frodietal,2001)
• Insecureavoidantaaachmentandtraumalinkedtoviolentoffending(Renn,2002)
THE IMPACT OF TRAUMA (t & T)
WorkingwithTrauma T & cumulative ‘t’ • “Children are much more vulnerable [to traumatic
experience]. They have fewer resources and are much closer to the possibility of death. Experiences that may not be a matter of life and death for an adult may well be experienced as such by a child” (Gerhardt, 2004, p.143)
• E.g. repeated separation, ‘put-downs’, rejection, prolonged shame – as well as T trauma.
AdverseChildhoodExperiences• EmoAonalabuse-Insulted/humiliated/feelingunloved(highdoseshame)
• Physicalabuse• Sexualabuse• Neglect• Parentalconflict/separaFon• DomesFcviolence• Parentalsubstance/alcoholmisuse• Parentalmentalhealthdifficulty• Parentalcriminality
Theimpactofadversechildhoodexperiences(ACE’s)
Theevidenceispreayclear:• ACE’sarecommon• ACE’sarehighlyinterrelated• ACE’spileupandhaveacumulaFveimpact• ACE’saccountforalargepercentageofhealth,socialandcriminologicalproblems
• PeoplewithexposuretoACE’sareeverywhereAcknowledgement: Sandra Bloom, 2015
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ACE’sasapublichealthconcern
“Adversechildhoodexperiencesarethemostbasiccauseofhealthriskbehaviours,morbidity,disability,mortalityandhealthcarecosts”
(Dr.VincentFelic,Co-authorAdverseChildhoodExperiencesStudy)FelicVJ,AndaRF,NordenbergD,WilliamsonDF,SpitzAM,EdwardsV,KossMP,MarksJS.RelaFonshipofchildhoodabuseandhouseholddysfuncFontomanyoftheleadingcausesofdeathinadults:TheAdverseChildhoodExperiences(ACE)Study.AmericanJournalofPrevenFveMedicine1998;14:245–258.
Trauma-organisedperson
Children,Adults,Families
Lackofbasicsafety/trust
LossofemoFonal
management
ProblemswithcogniFon
CommunicaFonproblems
Problemswithauthority
ConfusedsenseofjusFce
InabilitytogrieveandanFcipatefuture
Acknowledgement: Sandra Bloom, 2015
Impactofdisruptedaaachment/&trauma
– Our sensitivity to stress/threat – Our ability to process/interpret social
information – Our ability to empathise with others – Our ability to regulate emotions – Our capacity to seek support and comfort (co-
regulation)
• “Thosewhoseinternalsystemsarelessrobustbecauseoftheirearlyexperiences[ofaaachmentdisrupFonandtrauma]maysimplybemorevulnerabletoadversityandlessabletodrawonthepowersoftheirfrontalcortex[toprocessdistressandregulateemoFonandbehaviour]”(Gerhardt,2004)
VICARIOUSTRAUMA&PARALLELPROCESS
Workplacestressors
Blame
Demands of the Job
BURNOUT
Organisational Change
Office Politics
Funding & Resources
Unclear policies
Poor communication
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ParallelProcess• Whentwoormoresystems–whethertheseconsistofindividuals,groups,ororganisaEons–havesignificantrelaEonshipswithoneanotheroverEme,theytendtodevelopsimilarthoughts,feelingsandbehaviours.
• K.K.Smith,V.M.Simmons,andT.B.Thames,Thejournalofappliedbehavioralscience,1989.25(1):p.11-29.
Acknowledgement: Sandra Bloom, 2015
Organisations, like individuals, are living, complex, adaptive systems and that being alive, they are vulnerable to stress, particularly chronic and repetitive stress
Organisations, like individuals, can be traumatised and the result of traumatic experience can be as devastating for organisations as it is for individuals.
Acknowledgement: Sandra Bloom, 2015
Trauma-organisedstaff
STAFFLackofbasicsafety/trust
LossofemoFonal
management
ProblemswithcogniFon
CommunicaFonproblems
Problemswithauthority
ConfusedsenseofjusFce
InabilitytogrieveandanFcipatefuture
Acknowledgement: Sandra Bloom, 2015
Trauma-organisedsystem
OrganisaFon,sector,
communityLackofbasicsafety/trust
LossofemoFonal
management
ProblemswithcogniFon
CommunicaFonproblems
Problemswithauthority
ConfusedsenseofjusFce
InabilitytogrieveandanFcipatefuture
Acknowledgement: Sandra Bloom, 2015
• Confusedresponses:“Differentsystems,governedbydifferent
principles,fundeddifferentlyandwithdifferentaims,arealltryingtosupportyoungpeopleina
co-ordinatedmanner”Rogersetal.(2015)
Re-enactmentoftrauma:Acommonexperience:
“ExpecFngaprotecFveenvironmentandfinding
onlymoretrauma!”Dr.StephenSilver,(1986)AninpaFentprogramforPTSD:Contextastreatment.Traumaanditswake
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MANAGINGCOMPLEXITY-FORMULATION
TheBlindMenandtheElephant
DevelopingSharedUnderstanding–TeamFormulaFon PsychologicalFormulaFon
• Summarisethecoreneeds/problems• SuggesthowthedifficulFesmayrelatetooneanother,by
drawingon[mulFple]psychologicaltheoriesandprinciples;• Aimtoexplain,onthebasisofpsychologicaltheory,the
developmentandmaintenanceoftheclient’sdifficulFes,atthisFmeandinthesesituaFons;
• IndicateaplanofintervenFonwhichisbasedinthepsychologicalprocessesandprinciplesalreadyidenFfied;
• Areopentorevisionandre-formulaFon.
• Justahypothesistobetested…....
• JoehasdifficulFesrecognisingandregulaFnghisemoFons,inparFcularanger.Hisearly experiences ofwitnessing domesFc violence have led to him developing astress-responsesystemwhichcanbeseenas‘alwayson’.Thispermanentstateofhigh anxiety/hypervigilance, can explain some of his difficulFes in aaenFon,concentraFonandimpulsivity.Hisearlyaaachmentexperiences,characterisedbyperiods of neglect, have led to Joe developing a relaFvely independent, ‘street-wise’ approach to life. He is unlikely to seek help, preferring to boale up hisfeelingsanddealwith thingsonhisown. This leads toobsessive ‘over-thinking’and control, which in the short-termmay seem helpful, but in the longer termresultsinabuildupofemoFon–whichcoupledwithhissensiFvestress-responsesystem,canbeobservedina‘boale,boale,bang’cycle. Joeisalsolikelytohavehad reduced opportuniFes to develop effecFve emoFonal recogniFon andregulaFonskillsandconsequentlytheabilitytounderstandtheemoFonsofothers(empathy). IntervenFonaimedatteachingmorecogniFveskillsto‘control’angeror ‘understand’ the impactofhisbehaviourare thereforeunlikely tobehelpful,andmoreovermay teachhim to simply ‘boale’ thingsmore. Joewouldbenefitfrom building a relaFonshipwith an aauned caregiver, who is able to offer co-regulaFon, model vulnerability and label and discuss emoFon and regularopportuniFes to ‘download’ with a trusted other. He may also benefit fromexerciseandacFviFesthatallowhimto‘release’frustraFonsafely. JoemayalsobenefitfromsomeindividualintervenFonaimedathelpinghimtodevelopskillstorecogniseandmanageanxiety.
Joe has has ADHD, displayed violence and has ‘anger management’ difficulties – treatment = medication for ADHD and CBT/’thinking skills’ for anger management and ‘victim empathy’ D.A.R.T.INTERVENTIONPRINCIPLES
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Acoherent,sharedapproach
• NOTHINGPARTICULARLYNEW!!!• Aframeworkforustoworkto–safety/consistency/
sharedlanguage/sharedapproach• D.A.R.T.Meta-framework:
– Developmental– Aaachment(Bowlby,1998;Cri7enden,2005)– Risk– Trauma(developmentaltrauma&traumasystems)(VanderKolk,
2005;Briere&Sco7,2006,Saxeetal.,2007)
Aims• Reduceseverityandfrequencyofhighriskbehaviours
• RaisecaregiversensiFvity• FacilitateemoFonalregulaFon• FacilitatebehaviouralregulaFon• Promotepro-socialrelaFonships• Reduceplacementmoves• PathwayapproachtobuildadapFvedevelopment–startwheretheyareat!
Keyprinciples• Recreate‘typical’developmentalexperience–startwheretheyareat• ThosespendingthemostFmewithyoungpeoplearetheprimary
facilitatorsofchange• Recogniseparallelprocess–PRIMARYINTERVENTIONiswiththe‘system’• Ruleof167• Createcultureofsafety,sharedunderstandingandlearning
– Strongertogether– Well-beingandsupportofstaffisparamount– Coreprinciples,sharedvalues,sharedframework– Acknowledgementofthe‘threat’oftraumadysfuncFon– EffecFveriskassessmentandmanagement– Strongcultureofsupervision,supportandreflecFvepracFce
Process• Allstafftrainedinchilddevelopmentandaaachment/trauma
principles• Allyoungpeoplehaveapsychologicallyanddevelopmentally
informed,mulF-factorialformulaFonthatdrivesriskmanagementandintervenFon
• Systemfocussed:Psychologicallyinformedenvironment–‘everyinteracFonmaaers’
• Highstaffsupport/supervision/consultaFon• Clear‘real-life’outcomemonitoring–frequencyandseverity
ofhighriskbehaviours• Regularreviews• *Individualtherapy–beware:retraumaAsing/mismatched/
misAmed
IntervenFonPlanning• CreaFngsafety(throughrelaAonships)• Managingrisk&idenFfyingintervenFongoals(usingSPJ/formulaAon)
• GecngtheFmingright(developmentallyaUuned)• ChoosingtherighttherapeuFcapproach(usingourunderstandingofaUachmentstrategies)
• Getthepaceright(consideringtraumaandshame)• Beingaccountable(monitoringoutcomes)
IMPLEMENTINGINTOPRACTICEINTHESECUREESTATE
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• Specialistunit–aaachment/traumainformed(MH/YouthJusFce)• Maintainplacement–thereisnowhereelse!• RealisFcexpectaFons,long-termapproach• FormulaFondriven• Wholesystem–relaAonshipbased(EVERYinteracFon)–sharingand
modellingofemoFon(co-regulaFon)• Stafftraininginaaachment/traumaprinciples• ConsultaFon/supervisionofstaff–PIE• Coachingstaff-ParentwithP,A,C,E• Recreateasmanyaauneàco-regulateàrepair• Resistpressuretoindividually‘therap’(e.g.offencework)• Consequencesinlinewithriskmanagementplan• PACE/Fming/dosage
Aaachment/Traumainformedcare
EvaluaFon(N=41)Ryan&Mitchell,2011
Factors at time of admission to unit Violence
To other prisoners To staff
21 (51%) 14 (34%)
Damagetoproperty 10 (24%)
Self-harmCutting Ligature Burning Minor self-harm
11 (27%) 7 (17%)
3 (7%) 2 (5%)
Contact with mental health team 39 (95%)
Not in mainstream education 18 (44%)
Communication problems (language/speech/hearing/literacy) 12 (29%)
Serious substance misuse 28 (68%)
HoNOSCA scores at admission and discharge (N=41)
0
5
10
15
20
25
Disrup
tion/a
ggres
sion
Overac
tivity
Self-ha
rm
Substa
nce m
isuse
Schola
stic/l
angu
age s
kills
Physic
al he
alth
Halluc
inatio
ns/de
lusion
s
Somati
c sym
ptoms
Emotion
al sym
ptoms
Peer re
lation
ships
Self-ca
re/ind
epen
denc
e
Family
relat
ionshi
ps
Schoo
l atte
ndan
ce
T1
T2
Willow assessment (SABER) scores at admission and discharge
(N=41)
0
5
10
15
20
25
30
Social behaviour Aggressive or threatening behaviour
Self harm behaviour
Compliance with unit rules
Attending sessions / working
on problems
Self care/room care Social reintegration
T1
T2
Furtheroutcomes2013(N=28)
• BYI,TSCC,ARS,RQ(Selfreportaaachment)• Significantimprovementindepression,anxiety,anger,disrupFvebehaviour,PTS
• Increasein‘resilience’–relaFonships/opFmism/self-efficacy
• Significantimprovementinconfidence/securityofrelaFonships
• StabilisaFon:MoreFmespenton‘standard’regime(lessonbasic)
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THEFUTURE…….CHALLENGES&OPPPORTUNITIES
Challenges&OpportuniFes• Earlydays-verycomplex&highlychallenging• Emergingsupport-butonlyPARTofthejigsaw• OperaFonalisingtheoryintopracFcewithdifferentenvironmentalconstraints
• Time&realisFcexpectaFons• Dealingwiththetoxicnature–managingvicarioustrauma
• ?‘Managing’difficult/riskybehaviourratherthaneffecFveintervenFonstotackleit
• TRANSITIONS
Future….ChallengesandOpportuniFes
• REALISTICOPTIMISM:Adolescence&youngadulthoodisahugewindowofopportunity
• ItispossibletoplacealternaAveaUachmentmodelsalongsideother(mal)adapAvemodels!....andthenresolveunprocessedtraumaAcexperience
• Recognisingthesmallsteps…..secngyoursightsatanappropriatelevel
• ABSOLUTELYMUSTBEINCONTEXTOFWIDERPATHWAY–GENERALISATIONTOWIDEROFFENDERPOPULATIONANDCOMMUNITY–TRANSITIONPLANNING
• SupportfromYJBandNOMSe.g.– NaFonalPrisonofficertraining– Possibilityoffurther‘complexneeds’unitsacrosstheestate– LinktoPIPES&adultPDservices
• UnlesswerecogniseadapFveaaachmentprocesses&addressthe‘gaps’inthedevelopmentalprocess
• Unlessweappropriatelyrecogniseandassesstraumaanditseffects
• Unlikelytoimpactlong-termonbraindevelopment,regulatorysystem&nurturemoretypicaldevelopmentalprocesses
• UnlikelytohavepreparedtheYPfortheemoFonalchallengesofeffecFvelyprocessingtraumaFcmemories(indangerofre-traumaFsingand/orreinforcingpresentaFon)
• Unlikelytofundamentallychangebehaviour/compulsiontore-enact
BasicIdeas–ComplexDelivery!
KeyTakeaways• NosimplesoluFon!• Notwhatiswrong–butwhathashappenedtoyou?• Developmentallyinformedunderstanding–incl.aaachment&trauma
• DysfuncFonistobeexpected–weneedtoworktogethertobufferagainstit
• Recogniseparallelprocessesandimpactoftrauma• ManageriskandguideintervenFonviamulF-systemic/mulF-factorialformulaFon
• Keepholdingontohope!
Thank you
