Adapting Psychological Therapies for Individuals with ID and ASD

1. Adapting Psychological Therapies for Individuals with ID and ASD Pam Mount, Clinical Nurse Specialist Dr Lorraine Potts, Clinical Psychologist

2. Introduction…

3. Calderstones Partnership NHS Foundation Trust is a specialist learning disability service. The Trust is based in the Ribble Valley near the village of Whalley in Lancashire. We provide a specialist service to men and women with a learning disability and/or other developmental disorders, mental health problems, challenging behaviours and offending behaviour including in-patient assessment and treatment and community based services across the North West. www.calderstones. nhs.uk

4. ASD at Calderstones Reason for Admission Female: Aggression: 6 Breakdown of placement: 3 Male: Aggression: 8 Breakdown of placement: 17 Sexual Offending: 7 Fire setting/arson: 3 Crimes of acquisition: 1 Imprisonment of others: 1

5. We identified a group of service users to help us reflect on our practice. Our criteria were as follows: • Intellectual disability • ASD diagnosis • Has sexually offended • Has engaged with psychological treatment

6. AUTISTIC SPECTRUM DISORDER TOOLKIT Best Practice Learning Family and Community - Supportive Relationships ENGAGE ASSESS FORMULATE REVIEW KEEPING PEOPLE SAFE FUNCTION AND SOCIAL PARTICIPATION Resources / Policies / Environment

7. Whilst we reflected on the aspects of our practice that were different as a result of the individuals ASD, we also felt it was important to allow our service users to speak for themselves. 3 of our service users kindly offered to contribute to today's presentation and we have therefore included audio clips and some drawn material as we work our way through these slides.

8. Our first realisation:- Responses to therapy and the adaptations that we make are very different according to each service users individual needs. Each service user had strengths we could draw upon and differences or weaknesses which needed to be addressed.

9. Engage Assess Formulate Treatment Review

10. Engage The development of a ‘safe enough’ therapeutic relationship is key. This can take + + time. Some of the engagement styles we have come across: Answers all questions openly and honestly – over inclusive Too much detail? Socially acceptable response The ‘Perfect patient’ Fixed story Inflexible, unable to shift / evaluate / reflect

11. Assess • The following are some of the standard assessments we use for individuals who have sexually offended: • Questions on Attitudes Consistent with Sexual Offenders (QACSO) • Sexual Offender Self Appraisal Scale (SOSAS) • University of Rhode Island Change Assessment (URICA) • Adapted Relapse Prevention interview (ARP) • Risk of Sexual Violence Protocol (RSVP) • Assessment of Risk and Manageability in Intellectually Disabled Offenders (ARMIDILLO) • However, for individuals with an ASD we also need: • A good description of the individuals autism and how it affects them incl. social understanding, emotions and ToM • A good description of the individuals strengths and weaknesses • A good description of the individuals cognitive style

12. Assess Then it dawned on me he chose everyone with blonde hair Specific issues which require consideration when using assessment tools: • Open / closed questions • Concrete responses to psychometric questions • Need for reflection / insight • Understanding of emotional terminology / concepts • Information processing style • Understanding others perspectives • Misinterpretation of abstract words / concepts • One word – 2 meanings e.g. new as in recent or not been seen before

13. For example: (QACSO – Questionnaire on Attitudes Consistent with Sex Offences) • Do some women like men to stare at their (ToM) • bodies? • If a girl invites you back to her place for a (Social situation) • coffee is she really offering to have sex? • Do you think that it would take a woman (Emotions) • years or a few days to get over being flashed at?

14. Formulation Formulation is the process of making sense of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It is a bit like a personal story or narrative that a psychologist or other professional draws up with an individual and, in some cases, their family and carers.

15. Formulation • A good formulation: • Is specific to the individual • Is comprehensive • Has good face validity • Reflects theory and evidence base • Is shared by all • Identifies treatment pathways

16. Formulation Offending behaviour: Indecent Assault Offence: Touching a stranger in a sexual manner Power / dominance Grooming Poor social skills Sensory need Inability to start a conversation Fetish Fascination with ‘blonde hair’ Emotional Congruence Fear / threat

17. Treatment decisions are made on the basis of the assessment and formulation: • ASD Primary Focus • Developing practical skills to make offending less likely • Impact of their own offending on themselves – unpleasant • consequences • External controls • Rule based • Visual support tools • Offending Primary Focus – CBT approach • Group vs. individual therapy? • Offence account • Victim awareness • Good lives model • Self monitoring and staff observations • Risk assessment

18. FORMULATION

19. Treatment • ASD specific differences that we regularly come across: • Issues with Self Identity • Detached emotional style • Lack of theory of mind - empathy • Pre occupations / Special Interests • Social impairment • Sensory needs • Ability to internalise new rules and cognitive inflexibility • Central coherence – seeing detail rather than context • Anxiety • Communication difficulties

20. Treatment: Self identity He’s like a sponge in the environment he soaks up bits of everyone ‘GANGSTER’ ‘PSYCHOLOGIST’ ‘MODEL PATIENT’ ‘MODEL PAEDOPHILE’ • ‘Borrowed’ from: • Films • Life experiences • Other patients • Professionals • Family • Culture • Good Lives Model of offending • Using ‘New me Old me’ to create the non offending self

21. Treatment: ToM Victim Empathy: defined as the capacity to express compassion for victims Victim Awareness: motivators for change are not about the victim/family and friends but about the perpetrators family and friends • Improving emotional recognition using role play and Makaton pictures • Increasing their understanding of the term victim in its wider sense • Exploring the impact of their offence upon themselves • Drawing offence accounts • Completing offence accounts

22. Treatment: Detached emotional style It can be very difficult to hear the offence accounts of individuals who have an ASD. He told me about his offence like he was reading his shopping list • Matter of fact • Cold • Emotional incongruence • All about them • No emotional connection to the content in the room – leave you with it It’s all about what happens to him He’s just ‘weirding’ me out

23. Treatment: Sensory Issues How do I find a legal ‘sparkly ‘ Example 1: This individual says he doesn’t feel much. His only ‘sparkly’s’ arise when he’s drunk, when he sees violence and when he is sexually offending. The mere presence of something sensory flips him into a sexual place. Example 3: 4 out of the 10 individuals we looked at for this presentation had sexualised behaviours which were associated with urine and faeces. Example 2: A primary component of this individuals offence was smelling his hand after having made contact with females.

24. Review: What works? • Structure for those who are flexible • Sensory assessments • Visual aids • Social prompts • Role modelling and nurturing environments • Therapeutic communities – pros and cons • Group process • Aspiring to appropriate new identities • Negotiating with routines • Supporting anxiety management

27. Review: What about when it doesn’t work? Free time Community

28. It can be hard to tease things apart. Keep the individual in mind. Bring the best knowledge from ASD practice and the best knowledge from sexual offending practice. It’s a process of working it out with the client and with the team. Reviewing and refining.

29. Questions ?

30. Pam Mount is a Clinical Nurse Specialist (Learning Disabilities) and CAT Practitioner who takes a lead on the Calderstones Adapted Sex Offender Treatment Programme. Pam promotes a person centred, formulation based approach to understanding offending behaviour in order to develop risk plans supportive of the ‘Good Lives’ model. Pam.mount@calderstones.nhs.uk Dr Lorraine Potts is a Clinical Psychologist who has a specialist interest in working with individuals on the autism spectrum. Within this role, Lorraine undertakes ASD diagnostic and functional assessment and works closely with multi-disciplinary teams to develop clinical formulations to guide intervention. Lorraine also undertakes individual psychological therapy with individuals who have autism and who have offended. Lorraine.potts@calderstones.nhs.uk