Transcript 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)
[email protected]
Characteristics of young offenders
• Cognitive immaturity – many not yet have reached formal operational
thought. Therefore struggle with:
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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.
How best to intervene?
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
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
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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…
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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
TRAUMA RECOVERY MODEL
Skuse & Matthew
PRESENTATION / BEHAVIOUR
LAYERS OF INTERVENTION
Confidence
Achieving
goals
Independe
nce
 Provide a supportive safety net for
learning
 Guided goal-setting  Targets  Scaffolded
structure  Support into education / training
placement  Help to structure free time
constructively  Motivational interviewing
 Cognitive interventions e.g.
anger management, consequential
thinking
NEED
 Autonomy within the supported
context  Increased self-determination
FUTURE PLANNING: 
Increased self-belief /
esteem  Acceptance
of abilities /
potential
 Adult guided and supported
planning  Sense of purpose &
achievement – structured to
maximise the chances of success
INSIGHT / AWARENESS
 Calmer  Increased insight into
behaviour  More balanced selfnarrative
 Integration of old &
new self
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
FOUNDATIONAL BELIEF - REDEEMABILITY
 Need for
structure and
routine in
everyday life
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.
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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
TRAUMA RECOVERY MODEL
Skuse & Matthew
PRESENTATION / BEHAVIOUR
LAYERS OF INTERVENTION
Confidence
Achieving
goals
Independe
nce
 Provide a supportive safety net for
learning
 Guided goal-setting  Targets  Scaffolded
structure  Support into education / training
placement  Help to structure free time
constructively  Motivational interviewing
 Cognitive interventions e.g.
anger management, consequential
thinking
NEED
 Autonomy within the supported
context  Increased self-determination
FUTURE PLANNING: 
Increased self-belief /
esteem  Acceptance
of abilities /
potential
 Adult guided and supported
planning  Sense of purpose &
achievement – structured to
maximise the chances of success
INSIGHT / AWARENESS
 Calmer  Increased insight into
behaviour  More balanced selfnarrative
 Integration of old &
new self
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
FOUNDATIONAL BELIEF - REDEEMABILITY
 Need for
structure and
routine in
everyday life
Key features: Cognitive Readiness
Threshold
• It is some time before conventional
cognitive interventions can usefully be
applied
TRAUMA RECOVERY MODEL
Skuse & Matthew
PRESENTATION / BEHAVIOUR
LAYERS OF INTERVENTION
Confidence
Achieving
goals
Independe
nce
 Provide a supportive safety net for
learning
 Guided goal-setting  Targets  Scaffolded
structure  Support into education / training
placement  Help to structure free time
constructively  Motivational interviewing
 Cognitive interventions e.g.
anger management, consequential
thinking
NEED
 Autonomy within the supported
context  Increased self-determination
FUTURE PLANNING: 
Increased self-belief /
esteem  Acceptance
of abilities /
potential
 Adult guided and supported
planning  Sense of purpose &
achievement – structured to
maximise the chances of success
INSIGHT / AWARENESS
 Calmer  Increased insight into
behaviour  More balanced selfnarrative
 Integration of old &
new self
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
FOUNDATIONAL BELIEF - REDEEMABILITY
 Need for
structure and
routine in
everyday life
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]