The Scale Of The Problem

11/12/15Health WarningHigh Risk – High Harm - HighVulnerability:Working with young people whodisplay high risk behaviour The first principle of supporFng others is thatyou need to care for yourself first! LOOK AFTER YOURSELVESDr Andrew RogersConsultant Clinical & Forensic PsychologistChanging Minds UKadmin@changingmindsuk.comThe Scale of the Problem“It is impossible to understand the people webecome unless we understand the children wehave been”ReflecFons & observaFonsSecng the Scene - some observaFons Experience across 3 systems: Social Care/Mental Health/Criminal JusFce System Mental health services oden operate at the periphery (DNA/ Community CAMHS/YOT/LAC ResidenFal/Courts/Securewelfare/InpaFent MH/Prison (LASCH, SCH, YOI) Majority do not present with one ‘label’: Same client group, but different ‘treatment’ systems? Core group - complex histories of survival, aaachmentdisrupFon and trauma Present with high risk behaviours (to themselves and/orothers) Challenge whole systems – YP get passed between and withinuntreatable/’behavioural’)– ent/’Self-harmer’– CD/ADHD/PTSD/ASD/LD/ATTACHMENT D/BPD/ASPD/ & ? PSYCHOSIS!! DifficulFes ‘(re)-emerge’, intensify (higher risk) and becomeless ‘tolerated’ in adolescence (yr 9!!) But . oden idenFfiable earlier Highly resource intensive, difficult to change, frustraFnglysimilar outcomes Prognosis poor and highly likely transiFon to adult MH/criminal jusFce/forensic services1

11/12/15ReflecFons - Primary difficulFes Categorically / DiagnosFcally driven – too simplisFc IntervenFons are all too oden ‘prescribed’, single modality driven (e.g.CBT, medicaFon, ‘offence-focussed’) IntervenFons oden delivered to the individual without addressing thesystemic context Adult-driven: Lack of developmental perspecFve – ‘children are not miniadults’ Confused, chaoAc responses:“Different systems, governed by different principles, funded differently andwith different aims, are all trying to support young people in a co-ordinatedmanner” Rogers et al. (2015) Lack of co-ordinaFon and underpinning therapeuFc raFonale acrosssystems of careUNDERSTANDING THE PROBLEMChanging the fundamental quesFon:It’s not what is ‘wrong’with you?It’s what hashappened to you?Foderaro, 1991Brain DevelopmentMulFple & developmental perspecFves EvoluAon & SurvivalChild developmentBrain development / NeuroscienceAUachmentTraumaSystemicBiology, geneFcs and ology / Sociology / Desistance / DelinquencyKey is integraAng theories and operaAonalising into pracAce.Thinking (higher)BrainEmotionalBrainOld (‘reptilian’)BrainKey Ames for brain development: 0-2 yearsADOLESCENCEConAnuous development well into 20’s2

11/12/15Key assumpFons We are born very unfinished - to adapt andsurvive Early caregiving relaFonships and the impactof wider experiences [including trauma]‘sculpt’ the brain Our genes interact with our environment/experiences ‘in vivo’ Brain development conFnues well intoadulthood (25 )ATTACHMENTWhat is aaachment? Aaachment is an adapEve evoluFonary processand a means of survival Involves seeking proximity [through a7achmentbehaviour] to the primary caregiver when a childexperiences distress/discomfort/need The response of the caregiver helps the childdevelop a mental ‘model’ of themselves, othersand the world (relaAonships)Developmental process“Both the quality of care and security ofaaachment affect children’s later capacity ofempathy, emoFonal regulaFon, cogniFvedevelopment and behavioural control” (Kestenbaum etal, 1989)Aaachment is foundaFon of:– Understanding own and others behaviourand emoFonal experience (e.g. a sense ofempathy)– Understanding own worthiness (e.g. � Recognising emoFonal availability of othersand their ability to provide a ‘safe’environment (i.e. the ability to ask for help)– The ability to recognise and regulateemoAon– Social and moral development3

11/12/15Aaachment & Offending Insecure aaachment clearly linked to offendingbehaviour (Fonagy et al, 1996) 40 adult male ‘serious offenders’: 95% of hadinsecure aaachment, 53% A/C (van Ijzendoorn et al, 1997) 24 ‘psychopathic’ offenders had high rates ofdismissing (avoidant) aaachment style anddisorganised (unresolved). Related to rejecFngfathers and idealised mothers. (Frodi et al, 2001) Insecure avoidant aaachment and trauma linkedto violent offending (Renn, 2002)Working with TraumaTHE IMPACT OF TRAUMA (t & T)T & cumulative ‘t’ “Children are much more vulnerable [to traumaticexperience]. They have fewer resources and are muchcloser to the possibility of death. Experiences that maynot be a matter of life and death for an adult may well beexperienced as such by a child” (Gerhardt, 2004, p.143) E.g. repeated separation, ‘put-downs’, rejection,prolonged shame – as well as T trauma.Adverse Childhood Experiences EmoAonal abuse - Insulted / humiliated / feelingunloved (high dose shame) Physical abuse Sexual abuse Neglect Parental conflict / separaFon DomesFc violence Parental substance/alcohol misuse Parental mental health difficulty Parental criminalityThe impact of adverse childhoodexperiences (ACE’s)The evidence is preay clear: ACE’s are common ACE’s are highly interrelated ACE’s pile up and have a cumulaFve impact ACE’s account for a large percentage ofhealth, social and criminological problems People with exposure to ACE’s are everywhereAcknowledgement: Sandra Bloom, 20154

11/12/15ACE’s as a public health concernTrauma-organised personCommunicaFonproblems“Adverse childhood experiences are the most basiccause of health risk behaviours, morbidity,disability, mortality and healthcare costs”Problems withcogniFonProblems withauthorityLoss ofemoFonalmanagementConfused senseof jusFce(Dr. Vincent Felic, Co-author Adverse Childhood Experiences Study)Lack of basicsafety/trustFelic VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.RelaFonship of childhood abuse and household dysfuncFon to many of the leading causes of death in adults: TheAdverse Childhood Experiences (ACE) Study. American Journal of PrevenFve Medicine y togrieve andanFcipatefutureAcknowledgement: Sandra Bloom, 2015Impact of disrupted aaachment/& trauma– Our sensitivity to stress/threat– Our ability to process/interpret socialinformation– Our ability to empathise with others– Our ability to regulate emotions– Our capacity to seek support and comfort (coregulation) “Those whose internal systems are lessrobust because of their early experiences [ofaaachment disrupFon and trauma] maysimply be more vulnerable to adversity andless able to draw on the powers of theirfrontal cortex [to process distress andregulate emoFon and behaviour]” (Gerhardt,2004)Workplace stressorsBlameDemands of the JobVICARIOUS TRAUMA & PARALLELPROCESSBURNOUTOrganisationalChangeOffice PoliticsFunding &ResourcesPoorcommunicationUnclear policies5

11/12/15Parallel Process When two or more systems –whether these consist ofindividuals, groups, ororganisaEons – have significantrelaEonships with one anotherover Eme, they tend to developsimilar thoughts, feelings andbehaviours.Organisations, likeindividuals, are living,complex, adaptive systemsand that being alive, they arevulnerable to stress,particularly chronic andrepetitive stressOrganisations, like individuals,can be traumatised and theresult of traumatic experiencecan be as devastating fororganisations as it is forindividuals. K. K. Smith, V.M. Simmons, and T.B. Thames,The journal of applied behavioral science,1989. 25(1): p. 11-29.Acknowledgement: Sandra Bloom, 2015Acknowledgement: Sandra Bloom, 2015Trauma-organised staffTrauma-organised systemCommunicaFonproblemsProblems withcogniFonLoss ofemoFonalmanagementLack of basicsafety/trustCommunicaFonproblemsProblems withauthorityProblems withcogniFonConfused senseof jusFceSTAFFInability togrieve andanFcipatefutureAcknowledgement: Sandra Bloom, 2015 Confused responses:“Different systems, governed by differentprinciples, funded differently and with differentaims, are all trying to support young people in aco-ordinated manner” Rogers et al. (2015)Problems withauthorityLoss ofemoFonalmanagementLack of basicsafety/trustConfused senseof jusFceInability togrieve owledgement: Sandra Bloom, 2015Re-enactment of trauma: Acommon experience:“ExpecFng a protecFve environment and findingonly more trauma!”Dr. Stephen Silver, (1986) An inpaFent program for PTSD: Context astreatment. Trauma and its wake6

11/12/15The Blind Men and the ElephantMANAGING COMPLEXITY FORMULATIONDeveloping Shared Understanding –Team FormulaFonPsychological FormulaFon Summarise the core needs / problems Suggest how the difficulFes may relate to one another, bydrawing on [mulFple] psychological theories and principles; Aim to explain, on the basis of psychological theory, thedevelopment and maintenance of the client’s difficulFes, atthis Fme and in these situaFons; Indicate a plan of intervenFon which is based in thepsychological processes and principles already idenFfied; Are open to revision and re-formulaFon. Just a hypothesis to be tested . Joe has difficulFes recognising and regulaFng his emoFons, in parFcular anger. Hisearly experiences of witnessing domesFc violence have led to him developing astress-response system which can be seen as ‘always on’. This permanent state ofhigh anxiety/hypervigilance, can explain some of his difficulFes in aaenFon,concentraFon and impulsivity. His early aaachment experiences, characterised byperiods of neglect, have led to Joe developing a relaFvely independent, ‘streetwise’ approach to life. He is unlikely to seek help, preferring to boale up hisfeelings and deal with things on his own. This leads to obsessive ‘over-thinking’and control, which in the short-term may seem helpful, but in the longer termresults in a build up of emoFon – which coupled with his sensiFve stress-responsesystem, can be observed in a ‘boale, boale, bang’ cycle. Joe is also likely to havehad reduced opportuniFes to develop effecFve emoFonal recogniFon andregulaFon skills and consequently the ability to understand the emoFons of others(empathy). IntervenFon aimed at teaching more cogniFve skills to ‘control’ angeror ‘understand’ the impact of his behaviour are therefore unlikely to be helpful,and moreover may teach him to simply ‘boale’ things more. Joe would benefitfrom building a relaFonship with an aauned caregiver, who is able to offer coregulaFon, model vulnerability and label and discuss emoFon and regularopportuniFes to ‘download’ with a trusted other. He may also benefit fromexercise and acFviFes that allow him to ‘release’ frustraFon safely. Joe may alsobenefit from some individual intervenFon aimed at helping him to develop skills torecognise and manage anxiety.Joe has has ADHD, displayedviolence and has ‘angermanagement’ difficulties –treatment medication forADHD and CBT/’thinkingskills’ for anger managementand ‘victim empathy’D.A.R.T. INTERVENTION PRINCIPLES7