Interaction as a tool

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Interaction as a tool

• an inquiry in the practice of group leaders in a
  forensic treatment centre for people with a
  learning disability
• Anke C. ten Wolde
• Hoeve Boschoord

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lecture

• research, where why?
• theory treatment model
• methods Case study / Best Index
• results 4 styles of group work
• results the progress of clients
• results efficacy of the treatment model
• conclusion

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Research, where?

• forensic treatment centre
• a 24-hours institution
• learning disabilities (IQ range 50-90)
• offences challenging behaviour
• psychiatric co-morbidity
• age 16-60 (M30)
• 7 female 93 male
• 57 involuntary treatment (TBS order)

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Research, why?

• transparancy give account
• occasion new treatment model
• research topic dayly practice of group leaders
• three research questions1. Description of group
  work2. Results of clients 3. Evaluation of
  treatment model

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Treatment model (1)

• treatment is a process of learning
• learning in 4 different phases
• the content of what has to be learned is
  different for each phase
• all units are assigned to a phase
• treatment progress is visible
• it means moving to a different (more open) unit

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4 phases of treatment

• 1. Becoming accustomed (diagnostics,
  observation)
• 2. Committing oneself (becoming motivated)
• 3. Achieving (learning skills new behaviour)
• 4. Rehabilitation/reintegration(practising new
  skills in society)

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Treatment model (2)

• learning in the dayly interaction
• group leaders carry out treatment
• they offer learning situations
• therapeutic environment a deliberately
  constructed situation
• treatment goals are practised in dayly life
  integrated treatment
• participation of the client is of vital
  importance

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Therapeutic milieu
work
education
living
leasure time
integration
therapy
training
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Research methods

• Quantitative and qualitative inquiry
• multiple case study description of the work of
  group leaders
• Best (Behavioural Status) Index and follow-up
  study results of clients
• Model building testing the treatment model by
  practical experience

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Group work

• the methodical handling of the interactions in a
  group of patients
• aimed at group treatment goals
• and individual treatment goals
• 2 kinds of interactions- planned interventions-
  non-planned events

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Work characteristics

• maintain a day structure
• counselling individual clients
• reflection in the situation, immediately afterw
  ards, informal and formal
• teamwork safety issues
• commitment (strongly involved - professional
  distance)

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Unit 1 style

• Phase 1 admission, closed ward, no freedom,
  rules, structure
• clients court order, variety of disorders and
  offences
• impedements (clients) resistance (active,
  passive), victim role, blame the other, not open,
  social desirable behaviour, egocentric, no
  motivation, problems with women

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Unit 1 style

• Actions of group leaders
• observation and interpretation of behaviour
• make an individual day programme (token economy
  system)
• motivating to engage in treatment
• disapproval of the behaviour, but no rejection of
  the client
• Participation of clients in treatment with
  varying success

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Unit 2 style

• phase 2, closed ward, some freedom (vocational
  training open setting)
• Clients court order, aggression
• impedements of clients anger and aggression
  splitting staff lack of insight no acceptance
  of treatment and treatment plans no motivation
  not capable to recognize and express feelings

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Unit 2 style

• Actions of group leaders
• make treatment plans with small steps and rewards
  
• confronting clients with their problem behaviour
• make a referral to the offence
• motivating and stimulating clients
• participation compliance, admit own problem
  behaviour, being open

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Unit 3 style

• phase 3, half open ward, gradually more freedom
• Clients TBS SGLVG, (auto)agression, sexual
  problems.
• impedements of clients not capable to recognize
  and express feelings slow learning aggressive
  behaviour lack of motivation substance abuse
  alcohol, soft drugs

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Unit 3 style

• Actions of the group leader
• he/she builds a relationship
• learns the client social practical skills
• gives support and positive feedback
• controls the client uses corrections
• allows a stepwise increase of freedom and
  resposibility
• participation of the client follows therapies,
  performs his/her tasks, is open to staff

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Unit 4 style

• phase 4, open ward, directed towards return into
  the community
• Clients TBS SGLVG, the whole range of problem
  behaviour
• impedements of clients easyly influenced,
  difficulties to accept corrections building up
  tension no responsibility for their own
  behaviour

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Unit 4 style

• Actions of the group leader
• he/she takes clients seriously, makes agreements
• connects with individual possibilities
• talks often with clients, gives support
• supervision and check of behaviour of clients
  confronting clients with it
• motivating clients for their future
• participation of client takes responsibility, is
  future oriented

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Learning disability (1)

• in all treatment phases
• shortcomings in verbalising
• not capable to understand explanations
• not much information at one moment
• Not able to distuinguish main problems from minor
  problems
• No insight in social situations

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Learning disability (2)

• No generalisation to other situations
• Slow learning
• Lack of practical skills
• Lack of social skills
• Dificulties to recognize feelings in the person
  itself and in other persons
• Most adults try (often succesfully) to hide their
  shortcomings

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Ways of dealing with LD

• Observation, try to map out shortcomings
• Connecting with . Individuals own feelings,
  interests, language
• Adaptations use simple words, but stay
  respectfull, short duration of a talk, one
  subject at a time, comfortable situation
• Much explanation about social situations
• exercise in a situation (stepwise)
• Much repetition and patience, positive attitude

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Ways of dealing with LD

• Several ways to learn new behaviour
• Modeling do it yourself first, P looks
• Working together at a task (homework,
  housekeeping)
• Give an example how one could do it, but let the
  Person himself do the job
• Encouraging
• Give feedback about performance of a task,
  positive corrections
• Positive attitude

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Changes in style

• Clients kind of problem behaviour coming in at
  the moment
• Group leaders change of staff due to labour
  market
• Policy of the institution changing phases and
  units
• Policy of the government safety issues (more
  strict) different status (no possibility to
  exclude patients) fixed IQ range

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Results the progress of clients

• Measured with the Best Index (Behavioural Status
  Index)
• risk sub-scale
• insight sub-scale
• communication and social skills
• work and leisure activities
• care for oneself and the family

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Follow-up results after 2 years

• N28
• 75 succesfull (progression to the next phase or
  in the community)
• 25 no success set back in a closed ward or
  placement elsewhere
• 39 is in the community, mean time at risk 13
  months
• 1 recidivism (sexual offending of a non-forensic
  client)

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Evaluation of treatment model

• How clients go through the 4 phases?
• 54 passes through directly
• 46 is set back to an early phase
• big individual differences
• four patterns of learning (1) straight progress
  (2) progress, but very slowly (3) set back and
  start again (4) set back and stagnation

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Conclusion

• For people with LD the use of daily interaction
  in treatment is a powerfull tool
• a multi phasic treatment model (each phase a
  different focus) gives clearness to patients and
  staff
• special attention must be given to clients who
  are set back