1. Adapting Psychological Therapies for Individuals with ID and ASD
Pam Mount, Clinical Nurse Specialist
Dr Lorraine Potts, Clinical Psychologist

2. Introduction…

3. www.calderstones. nhs.uk
Calderstones Partnership NHS Foundation Trust is a specialist learning disability service.
The Trust is based in the Ribble Valley near the village of Whalley in Lancashire. We provide a specialist service to men and women with a learning disability and/or other developmental disorders, mental health problems, challenging behaviours and offending behaviour including in-patient assessment and treatment and community based services across the North West.
Calderstones is a specialist learning disability NHS Trust. We’re based in the northwest of england near clitheroe and have 220 beds across three sites. We provide enhanced support and medium and low secure services.
All of our service users have intellectual disabilities and additional difficulties.
All are detained under the mental health act.

4. ASD at Calderstones Reason for Admission Female: Aggression: 6
Breakdown of placement: 3
 Male:
Aggression: 8
Breakdown of placement: 17
Sexual Offending: 7
Fire setting/arson: 3
Crimes of acquisition: 1
Imprisonment of others: 1
At the current time approximately 20-30% of our population have a diagnosis of ASD OR are in the processing of being assessed.
The majority of our ASD service users are male, however the diagnosis rate within genders is similar: 21% of female population compared to 21% of male population.
With regard to primary reason for admission – perhaps the most striking detail on here is the no of individuals admitted because of a breakdown in their community placement.
Statistics also indicated a slightly longer than average stay for females and a slightly shorter than average stay for males.
NB data

5. We identified a group of service users to help us reflect on our practice. Our criteria were as follows:
Intellectual disability
ASD diagnosis
Has sexually offended
Has engaged with psychological treatment

6. FUNCTION AND SOCIAL PARTICIPATION AUTISTIC SPECTRUM DISORDER TOOLKIT
KEEPING PEOPLE SAFE
FUNCTION AND SOCIAL PARTICIPATION
AUTISTIC SPECTRUM DISORDER TOOLKIT
ENGAGE
ASSESS
FORMULATE
REVIEW
Best Practice Learning
Family and Community - Supportive
Relationships
Resources / Policies / Environment
The process of therapy is well contained within the context of the wider framework of care and it is important to acknowledge that the psychological treatment we engage these service users in is just one component of a wider context of treatment and support.

7. Whilst we reflected on the aspects of our practice that were different as a result of the individuals ASD, we also felt it was important to allow our service users to speak for themselves. 3 of our service users kindly offered to contribute to today's presentation and we have therefore included audio clips and some drawn material as we work our way through these slides.

8. Our first realisation:-
Responses to therapy and the adaptations that we make are very different according to each service users individual needs. Each service user had strengths we could draw upon and differences or weaknesses which needed to be addressed.

9. Engage Assess Formulate Treatment Review
So – to help us organise our thoughts we looked at the process of therapy and the differences / similarities associated with each stage.

10. Engage
The development of a ‘safe enough’ therapeutic relationship is key.
This can take + + time.
Some of the engagement styles we have come across:
Socially acceptable response
The ‘Perfect patient’
Answers all questions openly and honestly – over inclusive
Too much detail?
Fixed story
Inflexible, unable to shift / evaluate / reflect
Experience of therapy: clip Paul 30secs
Fixed story: AZ- One of the clients we reflected on is currently engaged in therapy. Saying that, it has taken a year for us to get to the point where the fixed ‘rigid’ story of offending is open for discussion rather than a repetition of the facts as he sees them. We are now in a position where we can start to jointly explore the formulation and jointly problem solve some of the difficulties that led to the offending.

11. Assess
The following are some of the standard assessments we use for individuals who have sexually offended:
Questions on Attitudes Consistent with Sexual Offenders (QACSO)
Sexual Offender Self Appraisal Scale (SOSAS)
University of Rhode Island Change Assessment (URICA)
Adapted Relapse Prevention interview (ARP)
Risk of Sexual Violence Protocol (RSVP)
Assessment of Risk and Manageability in Intellectually Disabled Offenders (ARMIDILLO)
However, for individuals with an ASD we also need:
A good description of the individuals autism and how it affects them incl. social understanding, emotions and ToM
A good description of the individuals strengths and weaknesses
A good description of the individuals cognitive style
A good description of the individuals autism and how it affects them:
Diagnostic reports, discussions with staff – if necessary we have a screening questionnaire which provides an overview of the individuals presentation, specific cognitive assessments – information through discussion with other member of the MDT

12. Then it dawned on me he chose everyone with blonde hair
Assess
Then it dawned on me he chose everyone with blonde hair
Specific issues which require consideration when using assessment tools:
Open / closed questions
Concrete responses to psychometric questions
Need for reflection / insight
Understanding of emotional terminology / concepts
Information processing style
Understanding others perspectives
Misinterpretation of abstract words / concepts
One word – 2 meanings e.g. new as in recent or not been seen before

13. For example: (QACSO – Questionnaire on Attitudes Consistent with Sex Offences)
Do some women like men to stare at their (ToM)
bodies?
If a girl invites you back to her place for a (Social situation)
coffee is she really offering to have sex?
Do you think that it would take a woman (Emotions)
years or a few days to get over being flashed at?

14. Formulation
Formulation is the process of making sense of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them.
It is a bit like a personal story or narrative that a psychologist or other professional draws up with an individual and, in some cases, their family and carers.

15. Formulation A good formulation: Is specific to the individual
Is comprehensive
Has good face validity
Reflects theory and evidence base
Is shared by all
Identifies treatment pathways

16. Formulation Offending behaviour: Indecent Assault
Offence: Touching a stranger in a sexual manner
Power / dominance
Grooming
Poor social skills
Sensory need
Inability to start a conversation
Fetish
Fascination with ‘blonde hair’
Emotional Congruence
Fear / threat

17. Developing practical skills to make offending less likely
Treatment decisions are made on the basis of the assessment and formulation:
ASD Primary Focus
Developing practical skills to make offending less likely
Impact of their own offending on themselves – unpleasant
consequences
External controls
Rule based
Visual support tools
Offending Primary Focus – CBT approach
Group vs. individual therapy?
Offence account
Victim awareness
Good lives model
Self monitoring and staff observations
Risk assessment
Can they be in a group?
Can they tolerate listening to other people?
Can group relationships be managed?

18. FORMULATION
Get the individual formulation right then everything else will slot into place

19. Treatment ASD specific differences that we regularly come across:
Issues with Self Identity
Detached emotional style
Lack of theory of mind - empathy
Pre occupations / Special Interests
Social impairment
Sensory needs
Ability to internalise new rules and cognitive inflexibility
Central coherence – seeing detail rather than context
Anxiety
Communication difficulties
We are not going to have time to discuss each of these but will pull some of them out to highlight in more detail:

20. He’s like a sponge in the environment he soaks up bits of everyone
Treatment: Self identity
‘GANGSTER’
He’s like a sponge in the environment he soaks up bits of everyone
‘PSYCHOLOGIST’
‘MODEL PATIENT’
‘MODEL PAEDOPHILE’
‘Borrowed’ from:
Films
Life experiences
Other patients
Professionals
Family
Culture
Good Lives Model of offending
Using ‘New me Old me’ to create the non offending self
Work towards finding a self identity that is positive, boosts self esteem and is non offending.

21. Treatment: ToM
Victim Empathy: defined as the capacity to express compassion for victims
Victim Awareness: motivators for change are not about the victim/family and friends but about the perpetrators family and friends
Improving emotional recognition using role play and Makaton pictures
Increasing their understanding of the term victim in its wider sense
Exploring the impact of their offence upon themselves
Drawing offence accounts
Completing offence accounts
Theory of mind may be thought of as a difficulty but in reality it isn’t. We don’t work with victim empathy – it is all about victim awareness.....
The jury is out as to whether victim empathy is an important area to treat in terms of ASOTP.

22. Treatment: Detached emotional style
It can be very difficult to hear the offence accounts of individuals who have an ASD.
He told me about his offence like he was reading his shopping list
Matter of fact
Cold
Emotional incongruence
All about them
No emotional connection to the content in the room – leave you with it
It’s all about what happens to him
He’s just ‘weirding’ me out

23. How do I find a legal ‘sparkly ‘
Treatment: Sensory Issues
How do I find a legal ‘sparkly ‘
Example 1: This individual says he doesn’t feel much. His only ‘sparkly’s’ arise when he’s drunk, when he sees violence and when he is sexually offending. The mere presence of something sensory flips him into a sexual place.
Example 3: 4 out of the 10 individuals we looked at for this presentation had sexualised behaviours which were associated with urine and faeces.
Example 2: A primary component of this individuals offence was smelling his hand after having made contact with females.

24. Review: What works? Structure for those who are flexible
Sensory assessments
Visual aids
Social prompts
Role modelling and nurturing environments
Therapeutic communities – pros and cons
Group process
Aspiring to appropriate new identities
Negotiating with routines
Supporting anxiety management

25. This is when he gets inappropriate thoughts
This is when he gets inappropriate thoughts. The top line is where those thoughts have taken him in the past. The bottom line demonstrates the new was he has learnt in order to deal with them.
Pictorial / visual
Helps him see things in more than one dimension
Gives him a script to follow in his head
Helps other people to support him
Has a new identity at the end
Shares information about risk.
These have been internalised – he still carries them around because that’s what he has been told to do but he has internalised them.

26. An achievement that he was particularly proud of was getting a female escort. Within his certificate he reviews the steps he has taken to be able to achieve that, the people who have helped, what is says about him to other people, how he felt about it and how he can do more of that. This process breaks down the steps that have been taken to achieve a positive result, makes them explicit and reinforces them.

27. Review: What about when it doesn’t work?
Free time
Community

28. It can be hard to tease things apart.
Keep the individual in mind.
Bring the best knowledge from ASD practice and the best knowledge from sexual offending practice.
It’s a process of working it out with the client and with the team. Reviewing and refining.

29. Questions ?

30. Pam Mount is a Clinical Nurse Specialist (Learning Disabilities) and CAT Practitioner who takes a lead on the Calderstones Adapted Sex Offender Treatment Programme. Pam promotes a person centred, formulation based approach to understanding offending behaviour in order to develop risk plans supportive of the ‘Good Lives’ model.
Dr Lorraine Potts is a Clinical Psychologist who has a specialist interest in working with individuals on the autism spectrum. Within this role, Lorraine undertakes ASD diagnostic and functional assessment and works closely with multi-disciplinary teams to develop clinical formulations to guide intervention. Lorraine also undertakes individual psychological therapy with individuals who have autism and who have offended.