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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

Three ill-defined problems

Intellectual deficiency Psychiatric disorder

Crime

National unit for mandatory care

Local institutions

Consultation-team

Main Residential

Unit

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

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På tide å bli enda bedre

Therapy can be conducted in many ways

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

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Target population

• Persons with ID convicted to mandatory care

• Persons with ID convicted to prison

• Persons with ID in custody

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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

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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”

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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

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Ecology

• KAOS understands that effective and

lasting change depends on transaction with

the environment

• treatment got to have the "real word" in

focus

“Fishbowl-therapy”

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

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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

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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”

Workbooks

”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

Anticipation of failure; systems

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

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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

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

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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

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BASIC

Feelings Friends Problemsolving Empathy Risk-analysis and planning Sexuality Relaxation Automatic thoughts

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EXTRA More about feelings Anxiety ABC SMART Anger and aggresion Self-harm and suicidal thoughts Rape Child molestation Arson

What kind of bad feelings do we have?

How do you recognize bad feelings?

How do you recognize that other people have bad feelings?

Skillstraining: FeelingsSkillstraining: Feelings““Bad feelings”Bad feelings”

Ex:Bad feeling, ANGRY

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?

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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"

Aims

• Reducing risk of new violence

• Improving social fuctioning in the local institution

• Improving quality of life

Pre- post- instruments

ADD DASH2 SCL90-r ADL-instruments FU (staffobservation of aggresion) Riskassesment; HCR/SVR/Armidillo Soas Customary checklists for targeted skills

Results from pre-post assesment

• The preliminary results is not yet analyzed

• Collaboration with the University i Trondheim (NTNU)

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

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

.. but at the same time realistic