Working with Risky Young People

Challenges and Solutions…

Dr David KingsleyConsultant Adolescent Psychiatrist

Woodlands Unit Cheadle Royal Hospital

dkingsley@affinityhealth.co.uk

puberty heightenspuberty heightensemotional arousability,emotional arousability,

sensation seeking,sensation seeking,reward orientationreward orientation

heightened vulnerabilityheightened vulnerabilityto risk taking & to risk taking &

problems in regulation problems in regulation of affect and behaviourof affect and behaviour

maturation of frontalmaturation of frontal lobes facilitateslobes facilitates

regulatory competenceregulatory competence

Early adolescence Middle adolescence Late adolescence

Affective and cognitive developmentin adolescence

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 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

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

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 Emotional Containment Containment

(‘safety’)(‘safety’)

Relational Relational Containment Containment (Attachments (Attachments

with caregivers, with caregivers, boundary setting)boundary setting)

Internal Sense Internal Sense of of

ContainmentContainment

Physical Physical ContainmentContainment

(A safe (A safe enough place)enough place)

Risks can be managed safely…

Risky BehaviourRisky BehaviourMild self-harm

Maybe I don’t need to cut myself

Self cutting

I am safe and I am ok

We can help to keep you safeYou are ok

Or can feel very unsafe…

Risky BehaviourRisky BehaviourMild self-harm

Oh my God – she nearly died

I have to die…

Life threatening ligatures

I am too dangerous to cope with

Unless in the right environment

Risky BehaviourRisky BehaviourMild self-harm

There is some hope for me

Life threatening ligatures

They can manage to keep me safe

Swiftly managed with 1:1 observation in secure unit

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…

Duff 2005

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When we have done all this…

We can consider

Therapy..!

Borderline Personality DisorderDSM 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

Health Warning

PERSONALITY DISORDERS CANNOT

BE DIAGNOSED IN YOUNG PEOPLE

AS THEIR PERSONALITIES

ARE STILL DEVELOPING

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 Increasing self-esteem and building

relationships Emotional Regulation Skills

Better understanding and management of emotions experienced

Distress Tolerance Skills 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…