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: 8Breakdown of placement: 17Sexual Offending: 7Fire setting/arson: 3Crimes of acquisition: 1Imprisonment of others: 1At 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 disabilityASD diagnosisHas sexually offendedHas engaged with psychological treatment
6 FUNCTION AND SOCIAL PARTICIPATION AUTISTIC SPECTRUM DISORDER TOOLKIT KEEPING PEOPLE SAFEFUNCTION AND SOCIAL PARTICIPATIONAUTISTIC SPECTRUM DISORDER TOOLKITENGAGEASSESSFORMULATEREVIEWBest Practice LearningFamily and Community - SupportiveRelationshipsResources / Policies / EnvironmentThe 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 EngageThe development of a ‘safe enough’ therapeutic relationship is key.This can take + + time.Some of the engagement styles we have come across:Socially acceptable responseThe ‘Perfect patient’Answers all questions openly and honestly – over inclusiveToo much detail?Fixed storyInflexible, unable to shift / evaluate / reflectExperience of therapy: clip Paul 30secsFixed 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 AssessThe 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 ToMA good description of the individuals strengths and weaknessesA good description of the individuals cognitive styleA 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 AssessThen it dawned on me he chose everyone with blonde hairSpecific issues which require consideration when using assessment tools:Open / closed questionsConcrete responses to psychometric questionsNeed for reflection / insightUnderstanding of emotional terminology / conceptsInformation processing styleUnderstanding others perspectivesMisinterpretation of abstract words / conceptsOne 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 FormulationFormulation 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 comprehensiveHas good face validityReflects theory and evidence baseIs shared by allIdentifies treatment pathways
16 Formulation Offending behaviour: Indecent Assault Offence: Touching a stranger in a sexual mannerPower / dominanceGroomingPoor social skillsSensory needInability to start a conversationFetishFascination with ‘blonde hair’Emotional CongruenceFear / threat
17 Developing practical skills to make offending less likely Treatment decisions are made on the basis of the assessment and formulation:ASD Primary FocusDeveloping practical skills to make offending less likelyImpact of their own offending on themselves – unpleasantconsequencesExternal controlsRule basedVisual support toolsOffending Primary Focus – CBT approachGroup vs. individual therapy?Offence accountVictim awarenessGood lives modelSelf monitoring and staff observationsRisk assessmentCan they be in a group?Can they tolerate listening to other people?Can group relationships be managed?
18 FORMULATIONGet the individual formulation right then everything else will slot into place
19 Treatment ASD specific differences that we regularly come across: Issues with Self IdentityDetached emotional styleLack of theory of mind - empathyPre occupations / Special InterestsSocial impairmentSensory needsAbility to internalise new rules and cognitive inflexibilityCentral coherence – seeing detail rather than contextAnxietyCommunication difficultiesWe 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:FilmsLife experiencesOther patientsProfessionalsFamilyCultureGood Lives Model of offendingUsing ‘New me Old me’ to create the non offending selfWork towards finding a self identity that is positive, boosts self esteem and is non offending.
21 Treatment: ToMVictim Empathy: defined as the capacity to express compassion for victimsVictim Awareness: motivators for change are not about the victim/family and friends but about the perpetrators family and friendsImproving emotional recognition using role play and Makaton picturesIncreasing their understanding of the term victim in its wider senseExploring the impact of their offence upon themselvesDrawing offence accountsCompleting offence accountsTheory 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 listMatter of factColdEmotional incongruenceAll about themNo emotional connection to the content in the room – leave you with itIt’s all about what happens to himHe’s just ‘weirding’ me out
23 How do I find a legal ‘sparkly ‘ Treatment: Sensory IssuesHow 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 assessmentsVisual aidsSocial promptsRole modelling and nurturing environmentsTherapeutic communities – pros and consGroup processAspiring to appropriate new identitiesNegotiating with routinesSupporting 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 / visualHelps him see things in more than one dimensionGives him a script to follow in his headHelps other people to support himHas a new identity at the endShares 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 timeCommunity
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.
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.