Developing a national model of care for individuals detained

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Developing a national model of care for
individuals detained under the ID(CCR) Act.
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(No Transcript)
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Mental Health ( Compulsory Assessment and
Treatment) Act 1992

• The definition of mental disorder meant risk
  associated with intellectual disability alone
  was no longer a justification for invoking the
  coercive powers of the Mental Health Act.

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Prior to 1992

• Some in Psychiatric Hospitals already.
• Others admitted and charges dropped.
• Individuals unfit to on serious charges were
  detained long term in hospital as special
  patients, and then patients.
• Others spent revolving time in prisons after
  conviction.
• Others diverted.

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Problems post 1992

• Unfit reaching end of maximum period of detention
  as special patient.
• Deinstitutionalisation well advanced.
• Risky people out there
• Something must be done.

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2 new laws

• Criminal Procedure (Mentally Impaired persons)
  Act. 2003.
• Intellectual Disability (Compulsory Care and
  Rehabilitation) Act 2003
• Only way into ID(CCR) Act orders is after being
  charged with an imprisonable offence.

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ID(CCR) Act is a disposition

• Unfit
• Special care recipient
• Care recipient for up to 3 years (renewable)
• No order made
• Fit and convicted
• Care recipient up to 3 years (renewable)
• Hybrid order
• Sentence to prison.

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Care Recipients

• Required to live in designated facilities
• Supervised or secure care.
• Only able to have leave from facility if leave
  approved.
• To receive care and rehabilitation according to
  care plan.
• A care manager may restrain a care recipient.....

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Who are these people

• What are we going to do with them.
• What are we going to do for them
• How do we do it
• Who with
• Why
• TINA
• BUSUWGU

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What features do the individuals being made
subject to ID(CCR) Act orders have in common.

• They are intellectually disabled.
• They have an IQ of 70 or below associated with
  significant deficits in adaptive functioning.
• They have offended
• They have often been victims of child abuse and
  or neglect
• They are emotionally inept
• They are on the edge, vigilant, expecting
  trouble.
• They are victims and they victimise
• They have a history of violence
• They do not play together nicely

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Many CRs have a partially environmentally caused
limitation of cognitive functioning

• Many have never previously been formally
  identified as intellectually disabled and/or
  received disability support services.
• These individuals ambivalent relationships with
  authority figures, lack of life skills, problems
  with affect regulation and impulse control make
  them a different group to those who established
  intellectual disability care providers were used
  to providing support services for.

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The introduction of the Act required the
development of new residential services

• The provision of rehabilitative options for
  convicted offenders implicit in the name
• The Act being applied in Youth Court
• Changes to the unfitness criteria
• And less draconian dispositions for the unfit
• Had led to
• Increasingly numbers of increasingly younger
  more damaged offenders are becoming Care
  Recipients.
• Because something must be done!

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The introduction of the Act has meant disability
services are finding themselves statutory
responsible for some really tricky people.

• The risks associated with
• The risks associated with
• The risks of managing
• Risky young men
• In the era of Risk management
• in a Risk averse time
• When everyone agrees something must be done

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NIMBY

• TINA
• BUSUWGU

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Contracts for provision of service are
prescriptive about requirements for security and
care

• However they contain no requirement for the
  provider to have a philosophy or model of
  assessment and rehabilitation.
• Why
• In New Zealand there has been very little formal
  training available in working with people with
  ID, let alone these working with these very
  challenging individuals.

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Providers have approached the how to and what to
do in different ways

• This could lead in time to services developing
  and implementing very different and potentially
  even contradictory approaches to the provision
  of care to CRs.
• The Judiciary has an understandable expectation
  that regardless of which Court they are making an
  order in that there should be some certainty
  about type and quality of service and containment
  an individual will receive should they choose to
  make that person a CR.

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The lack of an agreed an overarching model of
care and lack of training means

• In a crisis a staff member may need to rely on
  what ever approaches they have internalised which
  they think might be useful for managing men who
  exhibit bad behaviour and break the rules.
• These models of care have been distilled from
  general life experience and working with a more
  cognitively able, less impulsive and less
  limbically overdriven clientele and may have
  limited utility.
• And everyones approach will be different!

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What are their brains like?

• Our CRs general cognitive abilities, and
  particularly their frontal lobe and limbic system
  functioning has been impaired by
• Poor genetic endowment.
• Sub optimal suboptimal pre-and post natal
  developmental experiences.
• Head injuries
• The frontal lobes and limbic system are vitally
  important in affect recognition tolerance and
  regulation, and also impulse control

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What are the implications of this brain
impairment?

• We are dealing with a very vulnerable and
  victimised group.
• They have significant and often specific brain
  impairments that effect how they perceive and are
  set up to react to social situations.
• They are impulsive and emotionally dysregulated.
• Many have had poor developmental experiences.
• they have never had a chance to learn to see the
  world as anything other than a dangerous and
  unpredictable place.

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They can't stick to the rules of society

• They are not very bright.
• They are socially emotionally and financially
  disadvantaged.
• They end up with having more frustrations to
  cope with than most of us do.
• But have a limited range of coping strategies.
• They are very impulsive and very needy.
• When exposed to temptation they find it very hard
  to resist.

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What are the Psychological implications of their
developmental experiences

• Their experiences of caregivers has often been of
  poor with unpredictable care patterns oscillating
  between impingement and neglect.
• Many have considerable post traumatic
  symptomatology
• Many find it is safer to assume people bear them
  ill will that a chance.

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Requirements of a model of care.

• Provide an intellectually satisfying framework
  for staff to use to understand the nature of the
  field with in which they have chosen to work.
• Provide an appropriate framework within which
  staff can refine their understanding of their
  clients predicament in a way that helps
  assessment and management planning.
• Encourage the development of an appropriate
  professional stance to use in interactions with
  CRs
• Align the process of the doing the work at the
  coal face with the services theoretical approach
  

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Proposed classification of ID offenders detained
in RIDCA services.

• For use in assessment of offenders and in
  management.

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Two broad groups of offenders.

• Instrumental offending
• premeditated, controlled and done to achieve a
  predetermined end.
• Reactive offending.
• in response to situational stressors and or
  temptation. Aetiology can include a lack of
  modelling of appropriate ways of handling
  temptation and stress, the person not having
  other coping strategies, and/ or a lack of
  adequately developed biological control
  mechanisms.

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Reactive offending can potentially then be
further split

• A subgroup where the reactive offending is
  largely due to a lack of appropriate modelling
  and learning of how to handle the world and their
  feelings.
• While they may loose their temper at a certain
  point there is still an element of volitional
  control and afterwards a sense that they could
  have done things differently.

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A subgroup with extreme over reaction to minimal
provocation

• Lack of appropriate biopsychological control of
  response to emotional overload.
• The over reaction is almost as much a surprise
  to the CR as to those with them.
• Pressure, explode.
• Afterwards
• Tears and a sense of disbelief.

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Within this subgroup

• A group where, over time empathic but containing
  responses to their emotional dysregulation and
  their participation in anger management training
  enables then to learn how to manage better
  with less need for environmental control.
• A group who have minimal ability to change. Their
  explosive limbic overdrive is probably so
  organically determined, it is unlikely to ever be
  manageable other than by staff continuing to
  closely manage the environmental contingencies

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Potential advantages of splits into instrumental
and reactive offending and further subdivision of
the reactive group.

• Provides an framework for teams to use to derive
  a formulation of the CRs offending
• A vocabulary to use with others when discussing
  CRs
• Provides useful information for tailoring
  management
• Facilitates the early identification and exit
  from services of CRs where time in a compulsory
  care and rehabilitative is neither beneficial or
  necessary.

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Allow better continuity of care in the
transitioning of CRs

• Allow the early identification of those CRs who
  are never going to be able to benefit from
  rehabilitative or habilitative endeavours and may
  need long term containment.
• Transparent rationale for appropriate therapeutic
  risk taking
• Allow development of models of allocating and
  reviewing funding to RIDSS and RIDSAS services

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The Model in Practice

• Initial generic model required as classification
  only possible when rubber hits the road.
• "neuropsychosocial approach".
• Therapists may struggle with the
  neuropsychosocial approach when it conflicts with
  their perceptions about how people ought to
  behave.They may express the view that treatment
  techniques should follow those they use with
  their own unruly children. It has been known for
  a long time that this notion is misleading

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There is a stance staff need to be able to
achieve to work effectively both in the
assessment phase and in later management phases.

• The model is the antithesis of the he is doing
  this because he wants to get something and knows
  that if he behaves badly he will get it, so we
  have to defeat him approach.
• This is a damaged bloke. He has probably
  overreacted now because he feels stressed and
  confused. The way he is reacting now is probably
  what he has done in similar states of stress
  before. I need to not buy into reacting the way
  people usually do when he does this, instead I
  need to help him learn how to manage this
  feeling state without things getting too out of
  hand SO........
• I need to be able to let his emotion wash over me
  and join the Freud Squad.

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While at the same time being prepared to
intervene as part of a team if things do get out
of hand.

• The aim in each case will be see if it is
  possible to get the CR through their initial
  period of limbic overdrive to a place where they
  are not always reacting in a hostile and
  suspicious way
• After a period of time it should be possible to
  place the care recipient into one of three broad
  groups.

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Bowlby and Cleckleys not very bright boys

• Those individuals in whom a continuing
  neuropsychological approach may not be an
  appropriate management strategy because they
  present as psychopathic and their violence and
  rule breaking is mainly instrumental.
• This group may respond to motivational
  interviewing
• goodbye the time is not right for you to
  change,
• goodbye your brain in not right for you to
  change

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A group who have shown they have been able to
find a less hostile and suspicious place, and
who are now ready to learn habilitative
strategies.

• Continuing management using a neuropsychological
  approach.
• Modified Dialectic Behavioural Therapy
• Group work
• Occupational training
• Social training
• Moving their locus of control
• Developing sense of self, sense of self
  constancy, of being part of bigger groups and
  able to change.

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The severely limbically over-driven group.

• Are there some people who will continue to be so
  limbically overdriven that all the
  rehabilitation in the world is not going to
  change much.
• People so damaged or deficient they are likely
  to always be heavily dependent on external
  environmental control.
• Yes
• A challenge for the current New Zealand legal
  framework.