Theory Into Practice: Interventions for complex needs

Theory Into Practice: Interventions for complex needs Dr Tricia Skuse Clinical Psychologist All Wales Forensic Adolescent Consultation and Treatment Service (FACTS) Tricia.Skuse@wales.nhs.uk

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 Disability Est. 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

PRESENTATION / BEHAVIOUR LAYERS OF INTERVENTION NEED Autonomy within the supported context Increased self-determination Confidence Achieving goals Independence Provide a supportive safety net for learning Adult guided and supported planning Sense of purpose & achievement – structured to maximise the chances of success Guided goal-setting Targets Scaffolded structure Support into education / training placement Help to structure free time constructively Motivational interviewing FUTURE PLANNING: Increased self-belief / esteem Acceptance of abilities / potential Cognitive interventions e.g. anger management, consequential thinking Integration of old & new self INSIGHT / AWARENESS  Calmer Increased insight into behaviour More balanced self-narrative COGNITIVE READINESS Specialist therapeutic intervention re: trauma Containment Co-regulation Interactive repair Bereavement counselling WORKING THROUGH TRAUMA Return to difficult behaviours as trauma is processedClingy with staff / rejecting of staff Processing past experiences Grieving losses DISCLOSURE Maximum 1:1 times with adults Clear boundaries Maintenance of structure / routine 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 Need to develop trusting relationships with appropriate adults Need to develop a secure base READINESS TO BUILD RELATIONSHIPS WITH ADULTS Regular meals / bedtimes School Clear boundaries INSTABILITY / CHAOTIC ・Challenging behaviour (aggression, absconding, self-harm Chaotic lifestyle Drug use・Poor sleep / hygiene Offending Poor nutrition Inappropriate relationships Over-reliance on peers Need for structure and routine in everyday life FOUNDATIONAL BELIEF - REDEEMABILITY TRAUMA RECOVERY MODEL Skuse & Matthew

Key Features:Emphasison relationship with the young person Interactive Repairis 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

Key features: Cognitive Readiness Threshold • It is some time before conventional cognitive interventions can usefully be applied

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’

Tricia.Skuse@Wales.nhs.uk

Theory Into Practice: Interventions for complex needs