Transcript Slide 1

Working with Risky Young People
Challenges and Solutions…
Dr David Kingsley
Consultant Adolescent Psychiatrist
Woodlands Unit
Cheadle Royal Hospital
[email protected]
Affective and cognitive development
in adolescence
Early adolescence
Middle adolescence
Late adolescence
puberty heightens
emotional arousability,
sensation seeking,
reward orientation
heightened vulnerability
to risk taking &
problems in regulation
of affect and behaviour
maturation of frontal
lobes facilitates
regulatory competence
Steinberg 2005
Risk Taking Behaviours
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Deliberate self-harm and suicidal behaviour
Violence to others
Sexually harmful behaviour / violence
Sexual vulnerability / prostitution
Fire setting
Drug and alcohol misuse
What is the answer..?
Therapy..?
Risk Assessment & Management
are Therapeutic…
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Whenever working with high levels of risk, you
need to know what you are dealing with …
How high is the risk of WHAT happening with
WHOM in WHICH situations..?
When you fully understand a risk, you have
already made a start in reducing it…
Risk Assessment
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A ‘predictive’ process based on static factors
such as:
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Personal characteristics
Environmental circumstances
that predict the onset, continuity or
escalation of a risk…
Comparison of risk factors for early identification of
risk of suicidal behaviour and antisocial behaviour
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Family factors
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Household circumstances
Caregiver continuity
Supports & Stressors
Parenting style/parental psychopathology
Parasuicidal values & conduct
Child factors
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Abuse/neglect/trauma
ADHD traits
Mood Disorder & Comorbidity
Substance Use
Peer socialisation
Academic performance
Neighbourhood
Authority Contact
Parasuicidal attitudes & behaviour
Coping ability
Family factors
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Household circumstances
Caregiver continuity
Supports & Stressors
Parenting style
Antisocial values & conduct
Child factors
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Developmental Problems
Abuse/neglect/trauma
ADHD traits
Substance Misuse
Peer socialisation
Academic performance
Neighbourhood
Authority contact
Antisocial attitudes & behaviour
Coping ability
Risk Management
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A creative and dynamic process that uses
information from a thorough risk assessment:
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Predisposing factors
Triggers and early warning signs
Strengths and protective factors
Core beliefs that can be challenged
Skills that can be learned in therapy
to reduce and manage existing risk…
What is the answer..?
Therapy..?
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Before they can work therapeutically,
young people must feel ‘safe’…
Emotional
Containment
(‘safety’)
Relational
Containment
(Attachments
with caregivers,
boundary setting)
Internal Sense
of
Containment
Physical
Containment
(A safe
enough place)
Risks can be managed safely…
Risky Behaviour
Mild
Selfself-harm
cutting
Maybe I don’t
need to cut myself
We can help to keep you safe
You are ok
I am safe and
I am ok
Or can feel very unsafe…
Risky
Behaviour
Life threatening
Mild self-harm
ligatures
I have to die…
Oh my God –
she nearly died
I am too dangerous
to cope with
Unless in the right environment
Risky
Behaviour
Life threatening
Mild self-harm
ligatures
There is some
hope for me
Swiftly managed with
1:1 observation in secure unit
They can manage to
keep me safe
Secure Settings – therapeutic?
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Staff in acute hospital wards are not trained and
experienced in managing young people with
personality difficulties
Secure estate (SCHs, YOIs, STCs) often feel out
of their depth and untherapeutic
We need more specialist therapeutic secure
units that can manage the most risky young
people in a therapeutic way…
Therapeutic risk taking
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‘It is acknowledged that sometimes it is necessary to take
reasoned risks in order to achieve therapeutic gain with an
assessed individual. Total risk avoidance has been known to
lead to restrictive management, which can be damaging to
the welfare of the person and to the therapeutic relationship
between the service and the individual concerned’.
Department of Health
National Mental Health Risk Management Programme (2007)
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‘… in working with chronically suicidal individuals, there will
be times when reasonably high short-term risks must be
taken to produce long-term benefits’.
Linehan M (1993)
So what next..?
Therapy..?
All you need is love..?
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Risky young people will often have come from
chaotic unvalidating homes…
Many will have been emotionally, physically or
sexually abused…
Simple ‘positive unconditional regard’ from
consistent and nurturing caregivers will make
the biggest difference…
The Chair Model…
T H E R A P E U T IC
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SPECIALIST INTERVENTIONS
(CBT, DBT, Medication, Psychotherapy, Therapeutic
Communities, Schema Focus Thera py, CAT, etc)
Making Positive Connections
Working w ith People w ith
Personality Difficulties – What
Works?
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Duff 2005
When we have done all this…
We can consider
Therapy..!
Borderline Personality Disorder
DSM IV
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Frantic efforts to avoid real or imagined abandonment
Pattern of unstable and intense interpersonal relationships
Identity disturbance, unstable self image
Impulsivity that is self damaging
Recurrent suicidal behaviour, gestures or threats, or self
mutilating behaviour
Affective instability due to a marked reactivity of mood
Feelings of emptiness
Inappropriate, intense anger
Transient, stress-related paranoid ideation or severe
dissociative symptoms
Treat co-existing mental illness…
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Depressive Disorder
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CBT and/or SSRI Antidepressant
Quasi-psychotic / PTSD type symptoms
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May benefit from Atypical Antipsychotic
Surely now we’ve got to the therapy bit..?
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Yes, but therapy has its risks…
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A young person will have to face up to some
difficult realities in therapy
Their risk may escalate before it reduces
It is important to consider:
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The most suitable model for a young person
The timing of the therapy
Will they function best individually or in a group?
How well supported are they outside of the therapy?
Therapeutic alliance…
The most important aspect of therapy
(or at least the most important start…)
Evidence suggests that the relationship of
trust between client and therapist may be
at least as important as the model…
Roth A and Fonagy P (1996)
Cognitive Analytical Therapy
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Postulates that a set of partially dissociated ‘self-states’
account for the clinical features of borderline
personality disorder
Rapid switching between these self-states leads to
dyscontrol of emotions including intense expression and
a virtual absence (depersonalisation)
Therapy aims to formulate these processes
collaboratively, examining them as they occur in
treatment as well as in life experiences
Dynamic Psychotherapy
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This is based on a developmental model of personality
Treatment is generally long term
The aim of therapy is to understand the way in which
the past influences the present with the use of
interpretation
Treatment focuses on the therapeutic alliance between
patient and therapist, the individual’s emotional life,
and defenses
Therapy uses the relationship between patient and
therapist (transference) as a way to understand how
the internal world of the individual affects relationships
Dialectical Behavioural Therapy
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Interpersonal Effectiveness Skills
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Emotional Regulation Skills
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Better understanding and management of
emotions experienced
Distress Tolerance Skills
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Increasing self-esteem and building relationships
Crisis survival strategies and accepting reality
Mindfulness
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Learning to be in control of your mind rather than
letting it be in control of you…
A New Service Model…
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Background
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Lack of specialist inpatient services for young
people with emergent personality difficulties
posing high risks to self or others
Many such young people bouncing in and out
of secure social care placements or moving
through multiple community settings…
No consistency, ‘containment’ or therapeutic
momentum in these environments…
Woodlands
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A 10-bedded Therapeutic and Rehabilitative Low Secure
Unit for young people with emergent personality disorder
Opened February 2008 at Cheadle Royal Hospital
Planned admissions of 6-18 months’ duration
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Therapeutic model aiming to offer:
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A safe and containing physical environment for young people whose level
of risk may be uncontainable in any other setting
A culture of reflection and support both within the group of young people
and within the staff team
An active programme of activities, education and rehabilitation to build life
skills and enhance future functioning in the community
Specialist therapeutic interventions (CAT, Dynamic Psychotherapy, DBT
skills groups, medication) to address individual needs in the context of
nurturing and supportive nursing care
The possibility of managed step-down care to community (‘Lymefields’)
Lymefields
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A new partnership between Family Care Associates and Affinity Healthcare as
‘Young Alliance’
Joint funded placements that can continue beyond 18th birthday where
indicated
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Residential care in the community for young people with complex mental
health needs including risks to self or others
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Specialist care provided in partnership between:
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A residential team skilled and trained in working with young people with
significant mental health / personality difficulties and associated risks
An in-reach CAMHS team from Woodlands able to provide:
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Staff support, consultation and training for the residential team
Individual , Group and Family Therapy for Young People as indicated
Continuing medical and nursing overview and risk / medication management
A ‘seamless’ pathway from Woodlands into the community for young people
who may otherwise have been unable to make the transition from hospital or
secure care to community living
Come to our workshop this afternoon to find out more…