Bridging the gap between risk assessment and treatment: The KAOS and ARMIDILO
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Development and preliminary results from a cognitiv behavioral skillstraining program for mentally disabled patients in mandatory care: the KAOS program
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Bridging the gap between risk assessment and treatment: The KAOS and ARMIDILO
- 1. Development and preliminary results from a cognitiv behavioral skillstraining program for mentally disabled patients in mandatory care KAOS Svein Øverland, Clinical psychologist Sentral fagenhet, avd. Brøset, St. Olavs Hospital/ National unit for mandatory care 1
- 2. Three ill-defined problems Crime Intellectual deficiency Psychiatric disorder
- 3. National unit for mandatory care Main Residential Unit Local institutions Consultation -team
- 4. Aim of the National unit • To protect the society from further severe violence • To give persons convicted to mandatory care treatment for their behavioral problems
- 5. På tide å bli enda bedre 5
- 7. Therapy can be conducted in many ways
- 10. KAOS in a nutshell cognitiv behavioral therapy skillstraining risk-analysis and risk-planning in a groupsetting with alternativ modalities Milleu-therapists helps both in the groupsessions and with the home assignments and as liaisons to both the institution and the participants parents/siblings/workplace
- 11. Target population • Persons with ID convicted to mandatory care • Persons with ID convicted to prison • Persons with ID in custody 11
- 12. Patient characteristics • Mild to moderate mental retardation • Comorbid psychiatric diagnosis, such as psychosis, autism, depression, anxiety and sexual disorders • A history of severe violence/sexual violence/child molestation or arson • A history of avoiding or not completing therapy 12
- 13. Principle-based, not manualized • Ecological understanding and focus • Principles from evidence-based treatment for similar disorders • Empowerment • Psychoeducation • “Choosing from the meny” • “Anticipation of failure” 13
- 14. Principles from evidence-based treatment • There are no evidence-based treatment for patients with ID, severe violence, and comorbid severe psychiatric disorders • But KAOS applies principles from treatment of other patientgroups with severe problems • and treatment of patient with ID in general 14
- 15. Ecology • KAOS understands that effective and lasting change depends on transaction with the environment • treatment got to have the "real word" in focus 15
- 20. Empowerment Participation in KAOS is voluntary Participants can choose themes, but persuasion is used Participants can choose "helpers" Trainers and helpers adjust KAOS to the participants needs and learningstyles
- 23. 23
- 25. Patient characteristics • Mild to moderate mental retardation • Comorbid psychiatric diagnosis, such as psychosis, autism, depression, anxiety and sexual disorders • A history of severe violence/sexual violence/child molestation or arson • A history of avoiding or not completing therapy 25
- 26. Principle-based, not manualized • Ecological understanding and focus • Principles from evidence-based treatment for similar disorders • Empowerment • Psychoeducation • “Choosing from the meny” • “Anticipation of failure” 26
- 27. Workbooks
- 28. ”Choosing from the meny” • The participants chooses which of the themes they want to work with from the manual • The first ones should be rather simple, the last ones must relate to their indexcrime(s) • The participants make their own group- rules; reinforcers included
- 29. Anticipation of failure; systems
- 31. Anticipation of failure; systems Clinical psychology has a long tradition of “hyping” new therapies and techniques It is a challenge to apply therapy in a way that doesnt depend on a particular therapist, institution or administrative system in an ever changing world KAOS seeks a dialogue with parents, staff, cooperating agencies etc before starting treatment This is done in the first phases of KAOS
- 32. 32
- 33. Anticipation of failure; individuals • People in general overestimates their degree of control • And underestimates future risk • KAOS normalizes this • and insists that participants try to learn from their own and other participants experiences • KAOS applies roleplay, skillstraining and risk- scenarios for sharing succes and failures
- 34. Anticipation of failure; individuals • People in general overestimates their degree of control • And underestimates future risk • KAOS normalizes this • and insists that participants try to learn from their own and other participants experiences • KAOS applies roleplay, skillstraining and risk- scenarios for sharing succes and failures
- 35. KAOS consists two parts • BASIC • EXTRA • Two themes are chosen • Evaluation • Then two new themes, etc • Total KAOS is completed in two months or never 35
- 36. BASIC Feelings Friends Problemsolving Empathy Risk-analysis and planning Sexuality Relaxation Automatic thoughts 36
- 37. EXTRA More about feelings Anxiety ABC SMART Anger and aggresion Self-harm and suicidal thoughts Rape Child molestation Arson 37
- 38. Skillstraining: Feelings “Bad feelings” What kind of bad feelings do we have? How do you recognize bad feelings? How do you recognize that other people have bad feelings?
- 40. Skillstraining: Feelings “good feelings” What can you do to make the good feelings come back again? What can you do to make good feelings stay that way? What can you do to make other people get good feelings?
- 41. Present study (pilot study) only 5 participants in 4 institutions Observation and evaluation after completion of the first clinical phase Themes: "Understanding emotions" and “Friends" 41
- 42. Aims • Reducing risk of new violence • Improving social fuctioning in the local institution • Improving quality of life
- 43. Pre- post- instruments ADD DASH2 SCL90-r ADL-instruments FU (staffobservation of aggresion) Riskassesment; HCR/SVR/Armidillo Soas Customary checklists for targeted skills
- 44. Results from pre-post assesment • The preliminary results is not yet analyzed • Collaboration with the University i Trondheim (NTNU)
- 45. Preliminary result • Keep it simple! Its never to simple • Good feelings are contagious • We have to prepare the sessions better • Choice and use of reinforcers are very important • The role of trainer and co-trainer needs clarification • Roleplay, roleplay, roleplay, and in “real life” or simulated real life
- 46. Evaluation by the staff • Staff reports that the participants make better use of social skills • Non-participants as well • And even the staff • And we are optimistic
- 47. .. but at the same time realistic
Notas do Editor
- Im going to present a new treatmentprogram for a patient group whith these problems. At the same time. On e of the problems we are facing is that these concepts are not very well defined. Crime is of course about breaking the law. But the penaltysystem and prisons dont cooperate very well with the mental heaklth system or have much knowledge about persons with ID. Even though in Norway we now know that 10 persent of the prisonpopulants have a Mental retartdation as measured by a cutoff of IQ 85. The mental health system dont aways have knowledge about the needs of persons with ID. And all these conceps are not well defined, or at least regarding to persons with ID
- In Norway persons that commit severe crime can be sentenced to three different ” particular reactions ” ; based on if they were psychotic, have severe personality disorders or have a modereate to severe ID. This last group is sentenced to Mandatory care and are received in Trondheim at the Central Unit.
- In other wa treatment centerords; we are both a prison and
- But Hoh?
- But ” our ” group doesnt fit into these treatment. I think a basic principle in therapy has to do with power and responsibility. It is our duty to adjust treatment to the patients, not the opposite
- Insight will not necessary transform to behavior change
- And behaviour change will not necessary generalize to other situasions or last long without the same reinforcers
- Wiaiting for trial or verdict
- I will not og through all the principles here, but just highlight three of them
- This is the main problem with institutions
- Pharmacy, bowl
- paperdolls
- I will not og through all the principles here, but just highlight three of them
- Alle deltakerne har hver sin mappe, der de setter inn de ferdige produktene de arbeider med i timen eller som hjemmelekse. Her settes også inn diplomer for gjennomgått tema i KAOS. Mappa skal være både skrytealbum, men også kunne hjelpe deltakeren å huske hva man skal trene på, gjøre i vanskelig situasjoner.
- This is a picture from this phace
- Temaet vi begynte på etter påske er de dårlige følelsene. Målsetingene innefor temaet var; (Les lysbilde!) Vi satser på samme oppbygning som i første tema, først meg selv, så de andre. Det viste seg også at det var flere dårlige følelser enn gode følelser å spore i gruppa. Vi begynte med å vise bilder av personalet som viser forskjellige dårlige følelser, og det var artig for alle! Det ble vist frem følelser som deltakerne trodde de var alene om å ha.... Og som personalet ihvertfall ikke hadde...
- Other reasearch as shown that patients with psychosis is better at recognizing social situations and what to do, than actually doing it
- Del 3 blir hoveddelen i temaet «mestring av følelser.». Her skal vi sette sammen del 1 og del 2 og sammen finne strategier for hva vi skal gjøre når vi har det dårlig, eller når noen andre har det dårlig. Her ligger også hovedvekten av innhildet i manualen; hva kan man gjøre selv for å få det bra, hvordan hjelpe andre å få det bra? Men som sagt; først må vi vite hvordan det er å ha det bra, og hvordan det er å ha det dårlig. Og ikke minst, kunne kjenne igjen disse følelsene hos andre.
- Evalueringa av det vi hittil har gjort kan i hovedtrekk beskrives slik; Ingenting kan gjøres for enkelt. Vi overvurderer hele tiden hva brukerne forstår, og vi undervurderer hvor komplisert følelser egentlig er. Det så vi etterhvert også hos oss selv. Følelser er smittsomt. Dette blir en av læresetningene vi håper brukerne skal sitte igjen med. Om npoen har det bra, smitter det. Og det gjør det jaggu om noen har det dårlig også.... Manualen er samling med idèer og strategier. Oppbygningen av opplæringen måtte bli mer detaljert, med tydeligere målsettinger. Og vi måtte se alt i en helhet. KAOS-stjernene var veldig viktige. Og vi tror at summen av alle forsterkerne gjorde at vi ikke har plagdes med fravær eller uteblivelse fra KAOS. Som jo er det viktigste kriteriet for å lykkes; at deltakerne faktisk er tilstede. Vi så også at mye av arbeidet i KAOS-timene ble lagt til trener. Vi hadde ikke vært flinke nok til å definere hjelperrollen. Ble veldig slitsomt å holde fokus som trener, nå man samtidig skal hjelpe bruker å «svare rett», f.eks. Vi til slutt at det var viktig å gjøre øvelser hver time. Noen timer hadde vi bare med prating, og da var ikke konsentrasjonen det den burde være. Med øvelser ble det oppbrudd, fliring og læring.
- Les lysbilde!