Adapting Psychological Therapies for Individuals with ID and ASD

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Adapting Psychological Therapies for Individuals
with ID and ASD

• Pam Mount, Clinical Nurse Specialist
• Dr Lorraine Potts, Clinical Psychologist

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Introduction
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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. www.calderstones. nhs.uk
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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
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• 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

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• 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.

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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.

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Engage Assess Formulate Treatment
Review
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Engage
The development of a safe enough therapeutic
relationship is key. This can take
time. Some of the engagement styles we have come
across
Answers all questions openly and honestly over
inclusive Too much detail?
Socially acceptable response The Perfect
patient
Fixed story Inflexible, unable to shift /
evaluate / reflect
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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

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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

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• 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?

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Formulation
Formulation is the process of making sense of a
persons 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.
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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

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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
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• 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

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FORMULATION
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• 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

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Hes like a sponge in the environment he soaks up
bits of everyone
GANGSTER
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

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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

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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

Its all about what happens to him
Hes just weirding me out
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How do I find a legal sparkly
Example 1 This individual says he doesnt feel
much. His only sparklys arise when hes 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.
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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

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Review What about when it doesnt work?
Free time
Community
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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. Its a process of
working it out with the client and with the team.
Reviewing and refining.
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Questions ?
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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. Pam.mount_at_calderstones.nhs.uk

• 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.
• Lorraine.potts_at_calderstones.nhs.uk