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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 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… 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 A ‘predictive’ process based on static factors such as: 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 Family factors Household circumstances Caregiver continuity Supports & Stressors Parenting style/parental psychopathology Parasuicidal values & conduct Child factors Abuse/neglect/trauma ADHD traits Mood Disorder & Comorbidity Substance Use Peer socialisation Academic performance Neighbourhood Authority Contact Parasuicidal attitudes & behaviour Coping ability Family factors Household circumstances Caregiver continuity Supports & Stressors Parenting style Antisocial values & conduct Child factors Developmental Problems Abuse/neglect/trauma ADHD traits Substance Misuse Peer socialisation Academic performance Neighbourhood Authority contact Antisocial attitudes & behaviour Coping ability Risk Management A creative and dynamic process that uses information from a thorough risk assessment: 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..? 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? 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 ‘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) ‘… 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..? 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 A L L IA N C E C O N S I S T E N C Y C O M M U N I C A T I O N T E A M W O R K 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? B O U N D A R I E S Duff 2005 When we have done all this… We can consider Therapy..! Borderline Personality Disorder DSM IV 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… Depressive Disorder CBT and/or SSRI Antidepressant Quasi-psychotic / PTSD type symptoms May benefit from Atypical Antipsychotic Surely now we’ve got to the therapy bit..? Yes, but therapy has its risks… 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: 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 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 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 Interpersonal Effectiveness Skills Emotional Regulation Skills Better understanding and management of emotions experienced Distress Tolerance Skills Increasing self-esteem and building relationships Crisis survival strategies and accepting reality Mindfulness Learning to be in control of your mind rather than letting it be in control of you… A New Service Model… Background 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 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 Therapeutic model aiming to offer: 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 A new partnership between Family Care Associates and Affinity Healthcare as ‘Young Alliance’ Joint funded placements that can continue beyond 18th birthday where indicated Residential care in the community for young people with complex mental health needs including risks to self or others Specialist care provided in partnership between: 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: 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…