Treatment outside the therapy room: An experiential learning approach to PD awareness

Treatment outside the therapy room: an experiential

learning approach to PD awareness

Westgate Dangerous and Severe Personality Disorder (DSPD) Unit, November 2009

Targets for today

How can we engage DSPD participants to promote personal progress?

How people change: the need for insight within a long-term process of change?

Personality Disorder Awareness and an Experience of Parallel Therapy (PT)

Service-user experiences and how PT has evolved. How do we assess progress? How can progress be maintained using PT

principles?

Conventional treatment environments Conventional Offending Behaviour Programmes (OBPs) are

largely ‘classroom’ based. They provide the opportunity to acquire, discuss and explore

information. Often a good place to introduce and ‘model’ skills and

understanding. But give limited opportunity to generate deeper understanding

and apply this to ‘real-life’ situations. Knowledge and skills may be taught in isolation for short

periods and not revisited. Rely on participants to be solely responsible for practicing skills

once outside the classroom.

Imagine yourself as a DSPD service user What traits might you have that would get in the way of engaging

in conventional OBP’s? Some barriers to engagement:

Impulsivity Uncertain about change (can you change? do you want to?) Wanting to be seen in a good light at all times Mistrust/resentment of authority Difficulty collaborating with therapists Uncertain of release date – when will skills be used “for real” See things that happen to you as being beyond your control Low motivation

How would this impact on your ability to learn, or obstruct a ‘teacher’ prepared to help you develop skills?

The Goal…

…is GENERALISATION. This is the process by which you will start to apply a learned behaviour

in more situations than those in which it was first learned.

How can we make it more likely that DSPD prisoners will use the skills introduced in the treatment ‘classroom’, in real-world situations and scenarios…?

…and minimise prisoners simply saying and doing what they think the ‘teacher’ wants them to do (sometimes mistaken for long-term behavioural change)?

Getting to the Goal

Promoting skill generalisation is an essential part of achieving long-lasting behavioural change.

The Westgate Model of Change (WMC) provides a shared language to aid discussion about an individual’s progress in skills that target their problem’s in life.

It helps to generate meaningful treatment targets – essential for assessing treatment progress.

The Basis of the WMC

An adaptation of the Stages of Change Model (Prochaska & DiClemente, 1982)

Adequate problem recognition is seen as necessary before authentic behavioural change can occur.

Incorporates the importance of change in individual factors that relate to: Personality Disorder traits Other traits or factors associated with offending behaviour

Consistent with Proulx, Tardif, Lamoureux and Lussier (2000) - before the management of need areas is effective in reducing risk, participants need insight into how need areas contributed to the offending process. Accepting the impact of treatment needs on their life is the first step

Describing WMC

Precontemplation

No awareness of the problem and has no intention to change Using the Violence Risk Scale (VRS; Wong & Gordon, 2000), 98%

of current Westgate participants meeting DSPD criteria have Lack of Insight as at Treatment Need

Contemplation

Recognises problem areas and wants to overcome them but relevant behavioural change is not yet evident

Recognition of the need area as relevant to EITHER offending, or general lifestyle is sufficient for conclusion of contemplation

Preparation

The impact of problem areas is recognised in general lifestyle, offending and (ideally) personality disorder.

There are observable indications of change, i.e. we can see behavioural improvements.

However, changes are recent relative to the duration of the problem behaviour and tend not to be consistent over time or situation; lapses are frequent

Action

Behavioural changes seen in the preparation stage have been consistent and stable over an extended period of time, but have not yet been generalised to key high-risk situations

Maintenance

The individual is coping with need areas They use skills/techniques to consistently consolidate

and strengthen the gains made in the action stage. Changes have been generalised to high-risk situations

Lapsing and Relapse in WMC

What is Parallel Therapy?

An activity-based group intervention developed to complement formal, classroom-based treatment.

Designed to reinforce treatment objectives of specific Formal Therapy (FT) sessions through experiential learning activities.

An opportunity to take ‘processes’ from a classroom environment and practice them in environments that are closer to ‘real life’.

Delivered by Parallel Therapists, Formal Therapists and Complementary Regime Professionals.

Delivered to a staff-prisoner group, which is directed by prisoner participants.

Parallel Therapy Aims

To promote the development of insight and skills in the pursuit of Good Life Goals (Ward, 2002)

To facilitate the transition of coping strategies to everyday life

To make the prisoner progress during treatment observable: subject to behavioural monitoring

To provide activities that promote therapeutic alliance

PT Session Blueprint

Before: Staff Preparation (1 hr). During: detailed session plan with generic session

structure (1 hr). Check In – manage things that might stop the session

being a success Recap – reconnect with themes of formal therapy Main Exercise – behavioural experience Debrief - ‘learning cycle’ (Kolb & Fry, 1975) Check Out – disconnect from the experience

After: Facilitator Debrief and ‘write ups’ (1 hr).

The Teeter Totter Challenge

((Traits

((

((

Teamwork

Today’s Exercise

This is about developing insight into needs/PD traits.

Other PT exercises focus on skills generalisation. Task considered most relevant to a PD

conference, as it specifically targets the identification of traits.

Intention of helping participants transfer from a pre-contemplative state to a contemplative state for their need areas.

Insight as the first step in the change process

Today’s Exercise

The PT session is delivered in the Westgate Personality Disorder Awareness (PDA) module.

PDA is made up of 10 Formal Therapy classroom-based sessions and 2 PT sessions.

The module aims to: Increase participants’ understanding of personality Explore specific traits and behaviours associated with PDs (including

psychopathy) Explores diagnosis, cause, effects and implications

Having attended PDA formal therapy sessions, participants would have some relevant PD knowledge when going into today’s session.

They would have had limited opportunity to share their reflections on their own traits.

Today’s Exercise

8 volunteers required to actively participate What different groups have we got? We would like to get a good mix of people Some minor ‘roles’ will be assigned – who wants a minor role?

Roles for observers Session plans to follow the exercise Behavioural Checklists – pick a group member and record observations Get up, wander around, observe!

People are going to be working in close proximity - there may be an element of physical contact

Health & Safety

PT Session Aims

The exercise tests the ability of participants to accept change by asking them to adopt the role of leader and follower

During the de-brief participants are asked to give supportive and respectful feedback to one another

By the end …. Participant’s should have reflected on at least one of

their PD traits.

Today’s Session Structure

Check Inprepare the group to focus on the current task

and leave behind any issues that might be concerning them

Main Exercise Introduce the purpose of the sessionWhere will we be at the end of the session?

?

“Storyline”

MTC Version Your team must cross to the other side of the raging river. You have

bridges, but those bridges are not stable. Your team must manage to stay balanced as you cross the river. If the bridge dips into the river, the river will grab the tip of the bridge, it will sink into the river and the team will get tossed back to the river banks.

Westgate version At the Westgate Unit, your group is making a transition from needs

analysis (assessment) phase to the psycho-education (treatment) phase. You are moving forward together as a group and as with many journeys you may encounter unknown pitfalls and setbacks that will be destabilising for you and the group. You need to work together as best you can to make your personal transition go as smoothly as possible.

Session Rules

Group must stay in direct physical contact You have 20 minutes to make it across as a group At least 2 people need to have feet on the bridge at any

one time If all the team make the safety of the mid-point, the first

part of the task is complete. The role of “leader” will be rotated around the group The next “leader” will either volunteer or be picked by the

group You will be notified when it is time for a new “leader”

?

Complete the Teeter Totter Challenge

((Traits

((

((

Teamwork

Feedback

Feedback

The idea of the session is to help us explore personality disorder traits. You are now going to give each other feedback about how you got on. This means providing feedback on things that people might want to think about doing differently in the future. When giving feedback, we do not want you to identify traits. In this exercise, it is down to the person receiving the feedback to decide whether it relates to their PD(s). Just make an observation about their behaviour. Remember, exploring behaviours associated with a trait, does not automatically label that individual as having that trait.

Respectful – help the recipient reflect

Feedback

During the session, participants may express the power imbalance that exists when prisoners make personal disclosures and staff do not. Remind participants that the aim of the session is to give them the opportunity to demonstrate insight into their PD traits. Staff disclosures are not relevant to this objective and are unlikely to help participants reach this objective.

Each participant should have at least one piece of feedback to reflect on during the debrief.

Participant Debrief

Experiential Learning CycleConcrete

Experience

ObservePlan

Conceptualise

Experiential Learning Cycle(somewhat) simplified.

Experience

This stage involves the actual ‘doing’ of the skill.

The practicing of whatever it is that the learner is trying

learn.

Experience

ObservePlan

After the experience of the skill, the learner ‘observes’ the consequences of their

actions.

What happened when the skill was practiced?

Experiential Learning Cycle(somewhat) simplified.

Experiential Learning Cycle(somewhat) simplified.

Experience

Observe

Conceptualise

Making sense of what happened:

Relating it to previous experience and knowledge

Searching for understanding

Generalising, abstracting principles

Experiential Learning Cycle(somewhat) simplified.

Experience

ObservePlan

ReflectConceptualise

Considering the practical implications of new

understanding. Planning how you will put your new knowledge into

practice when you next attempt the skill.

Experiential Learning Cycle(somewhat) simplified.

Experience

ObservePlan

ReflectConceptualise

Applying new understanding or

knowledge to one’s actions.

Testing your ideas

Debriefs: Applying the ELC

Concrete Experience

Conceptualise ObservePlan

PT DEBRIEF

PT MAIN EXERCISE

Ask the group to reflect:What was it about the task that made these

behaviours more likely?What were your impressions of feedback you

received from the groupHow accurately did your feedback describe your

behaviour during the exercise?What did you value about each members

contribution?

Observe

Ask the group to form more general ideas:What piece of feedback was most relevant to you? How would this type of behaviour be unhelpful for

you before you came here? What events are likely to trigger the experience of

this trait?What PD trait/traits do you think the feedback you

received relates to?How can it help to have this insight?

Conceptualise

Ask the group to think about making ideas work in practice:What can you do to get objective feedback on

PD traits?How can you use the knowledge that you

have gained today about yourselves (within therapy and within interactions on the unit)?

Plan

Feedback from observers What observations do observers have? How would you feel if you were doing this for real? What useful information can be gained from this

process? We currently don’t present the ELC model to our service

users before PT. Do you think we should? Is it more likely to confuse rather than support learning?

What difficulties/challenges might exist in getting PT off the ground?

Staff-Prisoner Consultation

Primary Research Question:

“What are the challenges facing Parallel Therapy development and delivery at the Westgate DSPD

Unit?” Aims: To better understand the perspectives of key

stakeholders. To use knowledge about the experience of service

users and deliverers to inform PT development.

Study Design

Three Focus Groups: Focus Group 1: Prisoners participating in PT Focus Group 2: Prisoners expecting to participate within six

months Focus Group 3: Staff with experience in delivering PT

(including; Gym, Horticulture, Formal Therapists, Discipline Staff).

Each group ran in 2006 and repeated in 2007 Focus group questions centring around: the purpose of

PT, experiences of activities, links to formal therapy, Multidisciplinary Team dynamics

Constant comparative analysis

Findings: Prisoner Responsivity

A range of factors influenced willingness to engage in PT activities. ‘I’ve sometimes chosen not to go - got in a sulk’ strong and varying preferences for Complementary Regime activities

Many prisoners felt coerced into PT activities as a mandatory aspect of treatment

Success of session heavily dependent on the cooperation of the group Prisoners can ‘overpower what is going on in the session’

Staff reported difficulties promoting engagement Knowledge deficits of individual responsivity needs – poor use of

responsivity plans

Findings: Teambuilding

Breaking down barriers with staff Building trust within the group Having fun within treatment

Findings: Blurring of PT objectives Prisoners focused on secondary objectives

(“team building” rather than “skills building”) Some prisoners “stick” on the physical tasks

rather than “look at the emphasis, or the learning points”

Affirming therapeutic targets in abstract, fairly contrived group exercises is difficult - the environment needs to be more real.

Some activities stereotyped as having “childish” task content of “low personal relevance”.

Findings: Personal Relevance

Prisoners want ‘personal relevance’ difficult with ‘low ropes-style’ teambuilding tasks.

What can be achieved within a maximum security setting?

Broaden scope of PT to individualised and more flexible methods of reinforcing treatment objectives

PT on unit landings would be well supported by most prisoners Better application of skills development to the everyday lives of

prisoners

How can we promote skills?

Making Changes to PT

Development of a coaching service

A ‘purer’ apprenticeship model conscientious skills-building training based around the needs and

interests of the individual set in the context of a wider treatment framework

Retain the principles and structure of experiential learning… …move away from abstract scenarios in groups ….to working on an individual basis …on realistic, personally meaningful scenarios

Making Changes to PT

Prisoners have access to a member of staff identified as a ‘coach’

The aim of the coaching is to work at ‘ground level', alongside the prisoner on targets identified during needs analysis

Assisting the prisoner in use of the experiential learning cycle to put skills into practice

Making Skills Practice Real

A “behavioural experiment” approach involving meaningful scenarios where skills and ideas can be tested

Scenarios need to be ‘authentic’…representative of their lives/interests (e.g., dealing with conflict arising from domestic issues on the units)

Reflecting on the experience of new skills and the results of applying these promotes the development of more positive ideas about managing needs and personality disorder traits

How do we know progress is real? The Westgate Individualised Treatment Needs Analysis and

Progression (WITNAP) sets pre-treatment targets against which progress is measured

The WITNAP report, provides a rationale for why the prisoner has been categorised as DSPD and sets out a plan to for managing risk, need and SPD

The report includes: feedback from behavioural monitoring (incl. observations from WITNAP-PT) findings of collaboratively disclosed psychological tests offence analysis the findings of validated structured clinical judgement assessments of risk

and PD (e.g., VRS, HCR-20, PCL-R, IPDE, etc) a systematic formulation of the functional links between the individual’s

personality disorder traits and offending behaviour a plan for dealing with barriers to treatment (a responsivity plan)

Assessing progress

The assessment of change made in relation to pre-treatment WITNAP baselines is conducted at a number of junctures in treatment through the WITNAP Update process.

WITNAP Update involves collaborative discussions about the attainment of pro-socials skills, and the relationship between these and pre-treatment needs.

This provides an opportunity for clinicians and participants to develop a shared understanding of ongoing difficulties, and areas of skill development.

In this process, the WMC is used to enable both parties to exchange ideas about the progress of the participant in achieving successful change.

The Next Step

The Westgate Unit is just one part of the "end-to-end-management” of Personality Disordered offenders

In a 5 year period our aim is to: identify a participant’s PD(s) and the functional links between these and their risk. encourage contemplation of these factors. explore motivation for [and barriers to] change. introduce coping-strategies/management techniques. begin to explore these skills in practice [encourage a systematic means of

experimenting]. encourage participant’s to begin linking skills to risk. prepare them for a move to a site where they are the active agent in skills

development/testing.

Accurately communicate to progression sites the progress and needs of the offender’s they will receive

How do we maintain change?

‘Graduating’ the Westgate Unit An “Exit Report” is completed summarising the progress

made Situational factors likely to raise or lower risk are

highlighted, future recommendations are made and progression pathways are identified

The prisoner is referred on to site established as a What Works Informed and Resourced Environment (WWIRE)

This ‘graduate’ pathway begins with an initial Handover & Induction Session involving Westgate Treatment & Progression Staff, a Westgate Coach, and (from the receiving establishment) the DSPD Liaison and a Westgate-trained Progression Coach

Coaching in ProgressionSites Initially monthly meetings will take place with the

Progression Coach Westgate deliver training to Progression Coaches in the

Westgate Skills Directory and the Coaching methodology

Coaches can be any staff with the right competencies. Coaching at this stage is essentially a scaffolding role,

supporting the prisoner as he tries to maintain or improve behavioural change

Monthly meetings encourage reflection on the process of applying skills…increasing his responsibility and capability

What have we done today?

Explored the need for engaging treatment methods to promote progress

Explored the need for insight within a long-term process of change

Learnt about and experienced PT as a way to promote insight

Discussed service-user experiences and how the PT has evolved.

Introduced a method of assessing progress How progress can be maintained using PT

principles

Contact Us!

General Enquiries regarding any content in this presentation [email protected]

Enquiries relating to PT Coaching and DSPD Progression Pathways [email protected]

Enquiries relating to the Westgate Model of Change [email protected]