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

1. Treatment outside the therapy room: an experiential learning approach to PD awareness Westgate Dangerous and Severe Personality Disorder (DSPD) Unit, November 2009

2. 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?

3. 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.

4. 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?

5. The Goal… • …is GENERALISATION. • This is the process by which you will start toapply 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)?

6. 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.

7. 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

8. Describing WMC

9. 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

10. 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

11. 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

12. 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

13. 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

14. Lapsing and Relapse in WMC

15. 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.

16. 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

17. 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).

18. (( Teamwork (( Traits (( The Teeter Totter Challenge

19. 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.

20. Insight as the first step in the change process

21. 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.

22. 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

23. 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.

24. ? Today’s Session Structure • Check In • prepare 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 session • Where will we be at the end of the session?

25. “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.

26. ? 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”

27. (( Teamwork (( Traits (( Complete the Teeter Totter Challenge

28. Feedback

29. 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

30. 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.

31. Participant Debrief

32. Experiential Learning Cycle Concrete Experience Plan Observe Conceptualise

33. 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.

34. Experiential Learning Cycle(somewhat) simplified. Experience After the experience of the skill, the learner ‘observes’ the consequences of their actions. What happened when the skill was practiced? Plan Observe

35. Experiential Learning Cycle(somewhat) simplified. Experience Making sense of what happened: Relating it to previous experience and knowledge Searching for understanding Generalising, abstracting principles Observe Conceptualise

36. Experiential Learning Cycle(somewhat) simplified. Experience Considering the practical implications of new understanding. Planning how you will put your new knowledge into practice when you next attempt the skill. Plan Observe Reflect Conceptualise

37. Experiential Learning Cycle(somewhat) simplified. Experience Applying new understanding or knowledge to one’s actions. Testing your ideas Plan Observe Reflect Conceptualise

38. Concrete Experience PT MAIN EXERCISE Plan Conceptualise Observe PT DEBRIEF Debriefs: Applying the ELC

39. Observe • 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 group • How accurately did your feedback describe your behaviour during the exercise? • What did you value about each members contribution?

40. Conceptualise • 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?

41. Plan • 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)?

42. 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?

43. 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.

44. 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

45. 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

46. Findings: Teambuilding Breaking down barriers with staff Building trust within the group Having fun within treatment

47. 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”.

48. 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

49. How can we promote skills?

50. 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