Transcript Lesley Steptoe - Forensic Network

PBS Autism and Offending
Dr Lesley Steptoe
Chartered Forensic Psychologist
NHS Tayside, Forensic Learning Disability Services and
Behavioural Support and Intervention Acute Services
Dr Amy Kilbane
Highly Specialist Clinical Psychologist
Autistic Spectrum Condition Service
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Topics
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Service difficulties
Individual Assessment
PBS/Good Lives Model and Quality of
Life (QOL)
PBS and Psychological Interventions
Risk Management - How does that fit?
Case Study
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Service Difficulties
(Dein & Woodbury-Smith, 2009)
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Small but significant group
Specific vulnerability factors may increase risk
Typically forensic services struggle to provide
adequate placement
Difficulties in understanding an individuals everyday
functioning that contributes to shortfall in
appropriate care
Diagnosis rarely directly informs an understanding
of the persons specific difficulties
How does Autism affect Gary, John, Jim, Jean
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Individual Assessment
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Functional Assessment of behaviour
Sensory impairments
Dysfunctional coping strategies
Functions of challenging behaviour
Reinforcement schedules
Elements of psychopathy also need clarification
Understanding and working with these issues will
offer increased success in attempts at social
inclusion and preventing offending (Murphy, 2010)
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Positive Behavioural
Support (PBS)
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Primary prevention, Secondary
Prevention, Reactive Strategies
Autism – difficulties in understanding
the social world to varying degrees
Difficulties for intervention
Risk management
How does PBS fit?
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PCP and ELP
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Depicts how to support the individual using
Person Centred Planning (PCP) (important
TO the person) and Essential Lifestyle
Planning (ELP) (important FOR the person)
What’s important to the offender –
increased quality of life – desist from
offending?
What’s important for the offender – relapse
prevention - risk management
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Difficulties for
Intervention
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Rule based - moral rules?
Egocentric – lack of theory of mind (lack of
empathy) consequences to self of offending
Rigid thinking patterns– difficulties in
change
Good Lives Model – increase quality of life
and gain desistance from offending.
QOL for the Autistic person may be very
different to that of non autistic individuals.
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Combine PBS with
intervention
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Combine PBS with interventions
PBS provides consistency in support
Informs strategies that suit the individual
Avoids unilateral decision making by staff
Aims to maintain consistency of support to
prevent challenging behaviour and risk
management (reactive strategy)
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Case Study
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Mr A – 47 year old man - Autistic Spectrum
Disorder – CORO
1992 x 2 separate appearances –
(admonished, compensation order £150
and subsequently 1 year probation–
vandalism and obscene phone calls
1994 – vandalism to car – inpatient
assessment
1995 – vandalism to car – Probation Order 3
years direction to attend day care services
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Index Behaviour
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1996 –– Behavioural escalation, further
vandalism, threat to kill carer and being
found near her home carrying a knife.
Admitted to inpatient setting informally –
continued to express violent and murderous
fantasies in relation to carer – detained.
Breach of Probation, Criminal Justice
(Scotland Act x2 - Wilful and Reckless
Damage resulted in a Hospital Order,
Section 59 CPA)
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Background History
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Childhood – happy and uneventful
Attended local schools and transferred
to specialist LD school as a result of
educational difficulties
YTS placement – participated in a
number of work placements including
work as a sweeper for the Cleansing
Department
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Developing Issues
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1991 – contact with psychiatry due to an
obsessive attachment which he had
developed towards a female member of
staff
Noted as becoming aggressive when his
approaches to this member of staff were not
welcomed – obscene phone calls
Intervention showed little impact on his
presentation.
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Obsessive Behaviours
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Reluctance to discuss sexual matters –
worried at being labelled homosexual
Anxiety displayed at separation from the
particular carer
Telephoned her at 5.20am when he was
leaving for work as a road sweeper
1992 - Appeared at her house - noted as
following her to various different places –
continued to phone her inappropriately
along with episodes of damage to her
property
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Sexual Fantasy and Social
Isolation
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Fantasy – imagining he was having sex with
carer and her friend
Also noted as at times expressing wanting
to hurt her (related to damage to her car)
At home – mum trying to risk manage his
behaviour by locking him in his room – he
managed to leave and damage carers car.
He was described as socially isolated and as
having poor interpersonal skills
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Pornography and Sexual
Fantasy
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1996 – ideas of sexuality were derived from viewing
Pornographic videos involving rape amongst other
activities
Also noted as having sexual fantasies of rape
towards female nursing staff – harassing three
members of nursing staff for their phone numbers
and addresses
Reported wanting to rape one member of staff as
she had blonde hair - struck her on the face with a
towel
Similarities in appearance were noted between
member of staff and victim of index behaviour
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Challenging Behaviour
Otherwise presenting as:
 Challenging
 Awkward
 Stubborn
 Unco-operative
 Non Compliant at times
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Autistic Spectrum
Disorder
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Difficulties in approaching others to advise of
problems
Taking control of his environment – not getting up –
not going to workshop sessions – functions of CB –
to escape from task demands – expression of
emotional arousal and annoyance.
Initially in small group therapy – sitting away and
with his back to others
Turned up but refusal to engage
Uncomfortable in group situation – that’s ok?
Lack of theory of mind – lack of empathy
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MDT Intervention
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Forensic Psychology
Adapted SOTP based on the Good Lives Model
Allowed him to be alone within the group as long as
he attended and listened which he did
Once he became comfortable he integrated well
and is now a valued member of the group (12 men)
Focussed on rule based initiatives
Now excellent at advising the others of the rules to
risk and self management
Working with staff team to increase quality of life
(Good Lives Model and PBS)
Aim at desistance from offending behaviour
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Nursing Colleagues
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Nursing Colleagues
Daily working with challenging behaviour and risk
management – consistency –communication
Improving quality of life within a risk managed
framework – social outings, budgeting, football.
Risk – intermittent episodes of attraction to
particular female members of staff with blonde hair
– often two or three at a time
Mr A takes an avoidant strategy to trying to
problem solve this (dysfunctional coping strategy)
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Psychiatric Colleagues
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Introduction and management of
medication to assist with obsessional
thoughts
Ongoing monitoring of mental health
RMO management re CORO and as
part of MDT
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Occupational Therapy
colleagues
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Full timetable of work based activities
Increasing activities in line with QOL
Involved in risk management of Mr A
during work based activities with
nursing colleagues
Managing their own interpersonal style
to communicate effectively
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PBS Approach & Good Lives Model
– increase QOL.
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PBS approach looking to ‘need’ within Autistic
Spectrum Disorder to provide support through
primary and secondary prevention – increase
quality of life – manage triggers to behaviour
PBS a means of support at baseline and within early
indicators (triggers) of challenging/offending
behaviour
PBS Reactive Strategies - Dynamic Risk
Management (ELP)
Dynamic risk reduction – return to Primary and
secondary prevention to support Mr A within
Autistic Spectrum Disorder.
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PBS Autism and
Offending
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PBS Approach aims to prevent challenging
behaviour.
People with Autistic Spectrum Disorder may offend
for various reasons but they still require support
with how their Autism affects them.
Appropriate support through PBS results in a lower
level of arousal in general and allows for individual
dynamic risk management strategies to be
employed more consistently within a staff team
Avoids unilateral decision making and assists in
consistent dynamic risk management
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Ongoing
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Intermittent attraction to blond female staff
Through PBS he has learned to approach
staff to report difficulties
Non punitive
Reactive strategies in response to report
may reduce QOL for a limited period of time
Return to PBS once risk reduced =
increased QOL once again.
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Currently
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Mr A recently openly reported attraction to a
member of staff who had moved to another area
(change)
Obsessive thought processes reported (same)
Asked for support (Change)
Reported he did not wish to offend, quite distressed
and worried by the thought of doing so (Change)
Dynamic Risk – Reactive Strategy – ‘net tightened’
Increase in Medication
Two week – lower levels of stimulation
End of week 1 – improvement in behavioural
presentation
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Refs and interesting
reading
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Dein K. & Woodbury-Smith M. (2009). Asperger Syndrome
and Criminal Behaviour. Advances in Psychiatric Treatment;
15: 37-43.
Berney T. (2004) Asperger Syndrome from childhood into
adulthood, Advances in Psychiatric Treatment; 10: 341-51.
Murphy D. (2007). Hare PCL-R profiles of male patients with
Aspergers syndrome detained in high security psychiatric
care.. Journal of Forensic psychiatry and psychology; 18: 12026.
Rogers J., Viding E., Blair J., et al (2006) Autism spectrum
disorder and psychopathy: shared cognitive underpinnings or
double hit? Psychological Medicine; 36: 1789 - 98
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