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La Trobe Uni Presentation

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David Reid

on 3 September 2018

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Transcript of La Trobe Uni Presentation

Forensic Mental Health
Youth Justice Mental Health Program
Forensic Mental Health?
David Reid
YJMHP Coordinator

Things of interest?
what outcomes do we want?
Remand Units...
Youth Custody Health?
Key aspect of the vulnerable youth outreach element of redesigned CAMHS (0-25)
Developing mental health care systems that prioritize early intervention, continuity of care and age appropriate responses
“Juvenile offenders require a higher duty of care
than adult offenders”
(Australian Institute of Criminology, 2011)
Improved access to appropriate mental health treatment and support
Enhanced capability, skill and confidence of youth justice and mental health staff to respond effectively
Earlier identification and intervention
Improved prosocial functioning and life chances
Training Package:
1.What is Youth Mental Health?
2.Psychosis and young people
3.Managing self-harm and suicide in the remand setting
4.Anxiety Disorders and young people
5.Complex Trauma presentations in youth justice
6.Mental State Assessment Skills of remanded young people
7. Indigenous mental health
8. Autism Spectrum Disorders
Vulnerable but volatile

Emotional attachment difficulties (complex trauma)

Negative behaviours – “don’t get along”, overly reactive

Contained history until 12yo

DHS become involved

"I went to CAMHS once but I can’t remember why”
High school – deviating social trajectory:
•Age-related changes - Pseudo-maturity
•Associating with older peers
•Trouble with teachers, truancy from school
•Basic education failure – reading/writing (ID?)
•Unhappy kids but don’t present as depressed
•Engage in activities that keep them alive, but reduce self-esteem
Typical Remand clients?
Young People in Custody Health Survey - 2009
NSW DHS (242 young people)
Time spent on Remand is increasing...
YJMHC intervention is to meet basic needs
clinical assessment & case consultation
time-limited intervention to address distress
educate & support YJ staff. re. management on unit
referrals for support in community
Is it a coincidence that young people are most likely to offend as well as highest risk of becoming unwell?
Relationship between Mental Illness & Violence?
“There is a significant association between violence and schizophrenia, but less than 10% of societal violence is attributable to schizophrenia. Comorbid
substance abuse
considerably increases the risk” (Walsh, 2003)
Mental illness does appear to be related to a
small but significant
proportion of violence in society:
Megan's Law
Youth Psychopathy Debate
Problematic Behaviours
- stalking
- firelighting
The purpose of forensic mental health intervention is to treat a person’s psychiatric illness, improve quality of life, facilitate reintegration into community, and ultimately to reduce the likelihood of further offending.

1. Mental health needs

2. Criminogenic needs (dynamic risk indicators that directly affect the likelihood of criminal conduct)
1. address psychological needs
2. reduce young persons risk of recidivism
* The challenge for forensic mental health services is to provide rehabilitation services to young people in custody in a system that traditionally offers punishment and retribution.
Case Study?
Experience barriers to appropriate care for those with complex needs
More likely to suffer mental health problems
Mental health problems may predate, emerge during or develop as a consequence
Offending over lifespan
Violence & Young People...
* Adolescence is peak developmental period for acts of serious violence

* Violence in adolescence differs from adults, e.g.
- deviant peers have greater influence
- personality factors unstable
What works for violent young people?
* Punishment programs do not change behaviour
(no study has found that punishment-oriented programs reduce recidivism)

* Intervention must be swift

* Risk-Need-Responsivity Principles: High risk clients require resource intensive involvement
(intervention is often offence-specific rather than developmental needs-driven)
dynamic risk indicators that directly affect the likelihood of criminal conduct
Peak offending age is 15. Most don't offend again, even with no intervention
Even so, the vast majority of mental health service clients will not become violent.
E.g. 99.8% of persons with schizophrenia will not be arrested for violence in a given year (Wallace et. al. 1998)
Where does the funding come from?
* All aggression is purposeful; is it adaptive or maladaptive?

* The best predictor of future violence is past violence
- Significant cognitive impairment, e.g.
word knowledge of less than an 8 year old (Enaksha)
limited problem solving skills
difficulty giving reasons for a behaviour
- Poor insight (re. impact of offending behaviours, substance abuse, etc)
multiple problems are coexisting and linked (behaviours of concern aren’t always explained neatly by one box)
Jean Paul
visual hallucinations
poor self-care
e.g. Stutter when anxious
Sudanese background, e.g.
- trauma
- cultural view of illness
- culturally appropriate responses to distress
difficulties from early age
uncooperative with services
offending history
Management Plan
Visual Hallucinations:
"brain playing tricks..."
- visual distraction prompts:
When I feel scared at night I can...
- model breathing (take a big breath)
- gently start sentence
"...say it again Mikey..."
- avoid using:
"slow down"
- use simple language (words you can see)
- use short sentences (less than 9 words)
- direct statements
- model and communicate, e.g.
"Bang the door gently. It is too loud you are scaring me" (model how to knock on door gently)
"no" or "stop that"
- awoken at consistent time (8:15am?)
- clothes left on table
- shower
- make bed
- dirty clothes to laundry
- breakfast
- chores
Responding to distress
all staff must be aware of background & management plan
provide a consistent routine
ensure environment and staff behaviour is predictable
e.g. is the plan still to meet with unit supervisor each day?
thorough handover to other shift
inform casual staff as much as possible
Daily Routine
- avoid joining words if possible, e.g.
as soon as
as a consequence
- provide options to choose from rather than assuming he can generate his own solutions
- relate information back to him, e.g.
"when you played basketball..."
Visual Prompts?
Talk through steps while pointing to pictures
Standing at door:
re-affirm meeting time
provide activity options to redirect him
"When I feel scared at night I can...
light on
watch TV
read Bible
Recovery - What can we do?
Safety is essential. From a trauma perspective, youth act out when they feel threatened. Therefore, helping a youth feel safe should reduce the acting out and make the entire facility safer.
Structure and predictability can help a youth feel safe
Set limits appropriately
No violence
No yelling
No retaliation: Separate out your anger
You Dont Have to be a Therapist to be Therapeutic
Be consistent during interactions with youth
Model appropriate coping, anger management and problem solving
Follow up with the youth after a crisis
Each interaction presents an opportunity to build skills & foster a helping relationship
Teach Calming skills (how to relax?)
Recognizing physical signs of escalation
Teach Problem solving/Coping skills (any alterate responses?)
Using verbal responses rather than behavioral
Encourage seeking adult support
Build strengths and resilience
Work with natural talents and interests
e.g. Sports, music, drawing, cooking, writing
Strengths can include developing spiritual beliefs or cultural identity
What is case formulation?
A wholistic way of explaining a person’s difficulties in order to guide intervention.
A framework for organizing current and historical information to develop a biopsychosocial case formulation.
Presenting issues: What are the current problems the person faces primarily in terms of difficult behaviours emotions and thoughts.
Five Ps
Predisposing factors: What were the origins and development of the problems. There is an emphasis here on considering historical events and considering both the quantity and quality of these events in relation to the individual, e.g. where born, difficult past events and their meaning, family history of illness.
Precipitating factors: Need to identify what triggers the problems in terms of recent difficult situations and their relation to the person. Eg. Recent stressors/events, drug and alcohol use.
Perpetuating factors: What keeps the problem going? E.g. interpersonal stressors, medication non-adherence, drug and alcohol use, lack of meaningful activity.
Protective factors: What are the individual’s strengths? Personal qualities, social engagement, familial supports, relationships, willingness to engage with services.
Custodial settings around the world?
Prevalence of violence is high among youth

20-25% of males and 4-10% of females reporting one or more acts of serious violence

Prevalence of general delinquency even higher

Official crime rates peak sharply at age 15-18
Violence & young people
• Demonstrate an increase of more than 10% in reported overall offences from 2015.
2016 Crime statistics
(Victoria Independent Crime Statistics Agency)
• Contrary to media reports, there is not a diffuse crime wave among juveniles, but rather a small number responsible for prolific offending (1.6% of young offenders commit more than 20% of all youth offences), and this group showed a demographic profile of marked disadvantage.
Young people under supervision on an average day by supervision type, Australia, 2013-14 (rate)
Youth justice in Australia 2013-14 (source: AIHW)
‘High’ vs ‘low’ risk groups
High risk group:
many risk factors, few protective
Low risk group:
few risk factors, many protective
Note: even in high risk group, some do NOT go on to be violent;
similarly, in low risk group, some DO go on to be violent
Victorian YJ
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