1 pbs autism and offending dr lesley steptoe chartered forensic psychologist nhs tayside, forensic...
TRANSCRIPT
11
PBS Autism and PBS Autism and OffendingOffendingDr Lesley Steptoe Dr Lesley Steptoe Chartered Forensic PsychologistChartered Forensic PsychologistNHS Tayside, Forensic Learning Disability NHS Tayside, Forensic Learning Disability Services and Behavioural Support and Services and Behavioural Support and Intervention Acute ServicesIntervention Acute Services
Dr Amy KilbaneDr Amy KilbaneHighly Specialist Clinical PsychologistHighly Specialist Clinical PsychologistAutistic Spectrum Condition ServiceAutistic Spectrum Condition Service
22
TopicsTopics
Service difficultiesService difficulties Individual AssessmentIndividual Assessment PBS/Good Lives Model and Quality of PBS/Good Lives Model and Quality of
Life (QOL)Life (QOL) PBS and Psychological InterventionsPBS and Psychological Interventions Risk Management - How does that Risk Management - How does that
fit?fit? Case StudyCase Study
33
Service Difficulties Service Difficulties (Dein & Woodbury-Smith, 2009)(Dein & Woodbury-Smith, 2009)
Small but significant group Small but significant group Specific vulnerability factors may increase risk Specific vulnerability factors may increase risk Typically forensic services struggle to provide Typically forensic services struggle to provide
adequate placementadequate placement Difficulties in understanding an individuals Difficulties in understanding an individuals
everyday functioning that contributes to everyday functioning that contributes to shortfall in appropriate careshortfall in appropriate care
Diagnosis rarely directly informs an Diagnosis rarely directly informs an understanding of the persons specific understanding of the persons specific difficultiesdifficulties
How does Autism affect Gary, John, Jim, JeanHow does Autism affect Gary, John, Jim, Jean
44
Individual AssessmentIndividual Assessment
Functional Assessment of behaviourFunctional Assessment of behaviour Sensory impairmentsSensory impairments Dysfunctional coping strategiesDysfunctional coping strategies Functions of challenging behaviourFunctions of challenging behaviour Reinforcement schedulesReinforcement schedules Elements of psychopathy also need Elements of psychopathy also need
clarificationclarification Understanding and working with these issues Understanding and working with these issues
will offer increased success in attempts at will offer increased success in attempts at social inclusion and preventing offending social inclusion and preventing offending (Murphy, 2010)(Murphy, 2010)
55
Positive Behavioural Positive Behavioural Support (PBS)Support (PBS) Primary prevention, Secondary Primary prevention, Secondary
Prevention, Reactive StrategiesPrevention, Reactive Strategies Autism – difficulties in Autism – difficulties in
understanding the social world to understanding the social world to varying degrees varying degrees
Difficulties for interventionDifficulties for intervention Risk managementRisk management How does PBS fit?How does PBS fit?
66
PCP and ELPPCP and ELP
Depicts how to support the individual Depicts how to support the individual using Person Centred Planning (PCP) using Person Centred Planning (PCP) (important TO the person) and Essential (important TO the person) and Essential Lifestyle Planning (ELP) (important FOR Lifestyle Planning (ELP) (important FOR the person)the person)
What’s important to the offender – What’s important to the offender – increased quality of life – desist from increased quality of life – desist from offending?offending?
What’s important for the offender – What’s important for the offender – relapse prevention - risk management relapse prevention - risk management
77
Difficulties for Difficulties for InterventionIntervention Rule based - moral rules? Rule based - moral rules? Egocentric – lack of theory of mind (lack of Egocentric – lack of theory of mind (lack of
empathy) consequences to self of offendingempathy) consequences to self of offending Rigid thinking patterns– difficulties in Rigid thinking patterns– difficulties in
changechange Good Lives Model – increase quality of life Good Lives Model – increase quality of life
and gain desistance from offending.and gain desistance from offending. QOL for the Autistic person may be very QOL for the Autistic person may be very
different to that of non autistic individuals.different to that of non autistic individuals.
88
Combine PBS with Combine PBS with interventionintervention Combine PBS with interventionsCombine PBS with interventions PBS provides consistency in supportPBS provides consistency in support Informs strategies that suit the individualInforms strategies that suit the individual Avoids unilateral decision making by staffAvoids unilateral decision making by staff Aims to maintain consistency of support Aims to maintain consistency of support
to prevent challenging behaviour and risk to prevent challenging behaviour and risk management (reactive strategy)management (reactive strategy)
99
Case StudyCase Study
Mr A – 47 year old man - Autistic Mr A – 47 year old man - Autistic Spectrum Disorder – COROSpectrum Disorder – CORO
1992 x 2 separate appearances – 1992 x 2 separate appearances – (admonished, compensation order £150 (admonished, compensation order £150 and subsequently 1 year probation– and subsequently 1 year probation– vandalism and obscene phone callsvandalism and obscene phone calls
1994 – vandalism to car – inpatient 1994 – vandalism to car – inpatient assessmentassessment
1995 – vandalism to car – Probation 1995 – vandalism to car – Probation Order 3 years direction to attend day Order 3 years direction to attend day care servicescare services
1010
Index BehaviourIndex Behaviour
1996 –– Behavioural escalation, further 1996 –– Behavioural escalation, further vandalism, threat to kill carer and being vandalism, threat to kill carer and being found near her home carrying a knife. found near her home carrying a knife. Admitted to inpatient setting informally Admitted to inpatient setting informally – continued to express violent and – continued to express violent and murderous fantasies in relation to carer murderous fantasies in relation to carer – detained. – detained.
Breach of Probation, Criminal Justice Breach of Probation, Criminal Justice (Scotland Act x2 - Wilful and Reckless (Scotland Act x2 - Wilful and Reckless Damage resulted in a Hospital Order, Damage resulted in a Hospital Order, Section 59 CPA)Section 59 CPA)
1111
Background HistoryBackground History
Childhood – happy and uneventfulChildhood – happy and uneventful Attended local schools and Attended local schools and
transferred to specialist LD school transferred to specialist LD school as a result of educational as a result of educational difficultiesdifficulties
YTS placement – participated in a YTS placement – participated in a number of work placements number of work placements including work as a sweeper for including work as a sweeper for the Cleansing Departmentthe Cleansing Department
1212
Developing IssuesDeveloping Issues
1991 – contact with psychiatry due to an 1991 – contact with psychiatry due to an obsessive attachment which he had obsessive attachment which he had developed towards a female member of developed towards a female member of staffstaff
Noted as becoming aggressive when his Noted as becoming aggressive when his approaches to this member of staff were approaches to this member of staff were not welcomed – obscene phone callsnot welcomed – obscene phone calls
Intervention showed little impact on his Intervention showed little impact on his presentation. presentation.
1313
Obsessive BehavioursObsessive Behaviours
Reluctance to discuss sexual matters – Reluctance to discuss sexual matters – worried at being labelled homosexualworried at being labelled homosexual
Anxiety displayed at separation from Anxiety displayed at separation from the particular carerthe particular carer
Telephoned her at 5.20am when he Telephoned her at 5.20am when he was leaving for work as a road sweeperwas leaving for work as a road sweeper
1992 - Appeared at her house - noted 1992 - Appeared at her house - noted as following her to various different as following her to various different places – continued to phone her places – continued to phone her inappropriately along with episodes of inappropriately along with episodes of damage to her propertydamage to her property
1414
Sexual Fantasy and Sexual Fantasy and Social IsolationSocial Isolation Fantasy – imagining he was having sex Fantasy – imagining he was having sex
with carer and her friendwith carer and her friend Also noted as at times expressing wanting Also noted as at times expressing wanting
to hurt her (related to damage to her car)to hurt her (related to damage to her car) At home – mum trying to risk manage his At home – mum trying to risk manage his
behaviour by locking him in his room – he behaviour by locking him in his room – he managed to leave and damage carers car.managed to leave and damage carers car.
He was described as socially isolated and He was described as socially isolated and as having poor interpersonal skillsas having poor interpersonal skills
1515
Pornography and Pornography and Sexual FantasySexual Fantasy 1996 – ideas of sexuality were derived from 1996 – ideas of sexuality were derived from
viewing Pornographic videos involving rape viewing Pornographic videos involving rape amongst other activitiesamongst other activities
Also noted as having sexual fantasies of rape Also noted as having sexual fantasies of rape towards female nursing staff – harassing towards female nursing staff – harassing three members of nursing staff for their three members of nursing staff for their phone numbers and addressesphone numbers and addresses
Reported wanting to rape one member of Reported wanting to rape one member of staff as she had blonde hair - struck her on staff as she had blonde hair - struck her on the face with a towelthe face with a towel
Similarities in appearance were noted Similarities in appearance were noted between member of staff and victim of index between member of staff and victim of index behaviourbehaviour
1616
Challenging BehaviourChallenging Behaviour
Otherwise presenting as:Otherwise presenting as: Challenging Challenging Awkward Awkward Stubborn Stubborn Unco-operativeUnco-operative Non Compliant at timesNon Compliant at times
1717
Autistic Spectrum Autistic Spectrum DisorderDisorder Difficulties in approaching others to advise of Difficulties in approaching others to advise of
problemsproblems Taking control of his environment – not getting Taking control of his environment – not getting
up – not going to workshop sessions – functions up – not going to workshop sessions – functions of CB – to escape from task demands – of CB – to escape from task demands – expression of emotional arousal and expression of emotional arousal and annoyance. annoyance.
Initially in small group therapy – sitting away Initially in small group therapy – sitting away and with his back to othersand with his back to others
Turned up but refusal to engageTurned up but refusal to engage Uncomfortable in group situation – that’s ok?Uncomfortable in group situation – that’s ok? Lack of theory of mind – lack of empathyLack of theory of mind – lack of empathy
1818
MDT InterventionMDT Intervention
Forensic PsychologyForensic Psychology Adapted SOTP based on the Good Lives ModelAdapted SOTP based on the Good Lives Model Allowed him to be alone within the group as long Allowed him to be alone within the group as long
as he attended and listened which he didas he attended and listened which he did Once he became comfortable he integrated well Once he became comfortable he integrated well
and is now a valued member of the group (12 and is now a valued member of the group (12 men)men)
Focussed on rule based initiativesFocussed on rule based initiatives Now excellent at advising the others of the rules Now excellent at advising the others of the rules
to risk and self managementto risk and self management Working with staff team to increase quality of life Working with staff team to increase quality of life
(Good Lives Model and PBS)(Good Lives Model and PBS) Aim at desistance from offending behaviourAim at desistance from offending behaviour
1919
Nursing ColleaguesNursing Colleagues
Nursing ColleaguesNursing Colleagues Daily working with challenging behaviour and Daily working with challenging behaviour and
risk management – consistency –communicationrisk management – consistency –communication Improving quality of life within a risk managed Improving quality of life within a risk managed
framework – social outings, budgeting, football.framework – social outings, budgeting, football. Risk – intermittent episodes of attraction to Risk – intermittent episodes of attraction to
particular female members of staff with blonde particular female members of staff with blonde hair – often two or three at a timehair – often two or three at a time
Mr A takes an avoidant strategy to trying to Mr A takes an avoidant strategy to trying to problem solve this (dysfunctional coping problem solve this (dysfunctional coping strategy)strategy)
2020
Psychiatric ColleaguesPsychiatric Colleagues
Introduction and management of Introduction and management of medication to assist with medication to assist with obsessional thoughts obsessional thoughts
Ongoing monitoring of mental Ongoing monitoring of mental health health
RMO management re CORO and RMO management re CORO and as part of MDTas part of MDT
2121
Occupational Therapy Occupational Therapy colleaguescolleagues Full timetable of work based Full timetable of work based
activitiesactivities Increasing activities in line with QOLIncreasing activities in line with QOL Involved in risk management of Mr Involved in risk management of Mr
A during work based activities with A during work based activities with nursing colleaguesnursing colleagues
Managing their own interpersonal Managing their own interpersonal style to communicate effectivelystyle to communicate effectively
2222
PBS Approach & Good Lives PBS Approach & Good Lives Model – increase QOL.Model – increase QOL.
PBS approach looking to ‘need’ within PBS approach looking to ‘need’ within Autistic Spectrum Disorder to provide Autistic Spectrum Disorder to provide support through primary and secondary support through primary and secondary prevention – increase quality of life – manage prevention – increase quality of life – manage triggers to behaviourtriggers to behaviour
PBS a means of support at baseline and PBS a means of support at baseline and within early indicators (triggers) of within early indicators (triggers) of challenging/offending behaviourchallenging/offending behaviour
PBS Reactive Strategies - Dynamic Risk PBS Reactive Strategies - Dynamic Risk Management (ELP)Management (ELP)
Dynamic risk reduction – return to Primary Dynamic risk reduction – return to Primary and secondary prevention to support Mr A and secondary prevention to support Mr A within Autistic Spectrum Disorder.within Autistic Spectrum Disorder.
2323
PBS Autism and PBS Autism and OffendingOffending PBS Approach aims to prevent challenging PBS Approach aims to prevent challenging
behaviour. behaviour. People with Autistic Spectrum Disorder may People with Autistic Spectrum Disorder may
offend for various reasons but they still require offend for various reasons but they still require support with how their Autism affects them.support with how their Autism affects them.
Appropriate support through PBS results in a Appropriate support through PBS results in a lower level of arousal in general and allows for lower level of arousal in general and allows for individual dynamic risk management strategies individual dynamic risk management strategies to be employed more consistently within a to be employed more consistently within a staff teamstaff team
Avoids unilateral decision making and assists Avoids unilateral decision making and assists in consistent dynamic risk managementin consistent dynamic risk management
2424
OngoingOngoing
Intermittent attraction to blond female staffIntermittent attraction to blond female staff Through PBS he has learned to approach Through PBS he has learned to approach
staff to report difficultiesstaff to report difficulties Non punitiveNon punitive Reactive strategies in response to report Reactive strategies in response to report
may reduce QOL for a limited period of may reduce QOL for a limited period of timetime
Return to PBS once risk reduced = Return to PBS once risk reduced = increased QOL once again. increased QOL once again.
2525
CurrentlyCurrently
Mr A recently openly reported attraction to a Mr A recently openly reported attraction to a member of staff who had moved to another area member of staff who had moved to another area (change)(change)
Obsessive thought processes reported (same)Obsessive thought processes reported (same) Asked for support (Change)Asked for support (Change) Reported he did not wish to offend, quite Reported he did not wish to offend, quite
distressed and worried by the thought of doing so distressed and worried by the thought of doing so (Change)(Change)
Dynamic Risk – Reactive Strategy – ‘net tightened’Dynamic Risk – Reactive Strategy – ‘net tightened’ Increase in MedicationIncrease in Medication Two week – lower levels of stimulationTwo week – lower levels of stimulation End of week 1 – improvement in behavioural End of week 1 – improvement in behavioural
presentationpresentation
2626
Refs and interesting Refs and interesting readingreading Dein K. & Woodbury-Smith M. (2009). Asperger Dein K. & Woodbury-Smith M. (2009). Asperger
Syndrome and Criminal Behaviour. Syndrome and Criminal Behaviour. Advances in Advances in Psychiatric TreatmentPsychiatric Treatment; 15: 37-43.; 15: 37-43.
Berney T. (2004) Asperger Syndrome from childhood Berney T. (2004) Asperger Syndrome from childhood into adulthood, into adulthood, Advances in Psychiatric TreatmentAdvances in Psychiatric Treatment; 10: ; 10: 341-51.341-51.
Murphy D. (2007). Hare PCL-R profiles of male patients Murphy D. (2007). Hare PCL-R profiles of male patients with Aspergers syndrome detained in high security with Aspergers syndrome detained in high security psychiatric care.. Journal of Forensic psychiatry and psychiatric care.. Journal of Forensic psychiatry and psychology; 18: 120-26.psychology; 18: 120-26.
Rogers J., Viding E., Blair J., et al (2006) Autism Rogers J., Viding E., Blair J., et al (2006) Autism spectrum disorder and psychopathy: shared cognitive spectrum disorder and psychopathy: shared cognitive underpinnings or double hit? Psychological Medicine; underpinnings or double hit? Psychological Medicine; 36: 1789 - 9836: 1789 - 98