Successful Sexual Issues Treatment Completion in as Little as 6 Months: The Benefit of Trauma Informed Approached Dominick DiSalvo MA, LPC Nationally Certified Trauma Focused Cognitive Behavior Therapy (TF-CBT) Therapist Senior Director of Clinical Services at KidsPeace
Discloser Statement Author is employed by KidsPeace Corp. Author has no conflicts of interest to disclose.
KidsPeace Corporation at a Glance Founded in 1882 during smallpox epidemic Services in ten states and D.C. Range of services residential treatment, 228 beds in PA free-standing psych. hospital, 120 beds accredited educational services foster care community-based treatment History JCAHO Accredited PA Residential includes specialized services Co-occurring intellectual disabilities Sexual issues (PA, Georgia) Trauma Diagnostic Tri-Care Autism (Maine)
Pennsylvania Sexual Issues Program Two Stand Alone L Shape Houses Max capacity of 32 clients Staff to Client Ratio 1:3 Clinician to Client Ratio 1:8 Age Ranges 9-18+ Martin Luther King House 9 to 13 years of age Robert Fulton House 14-18+ years of age Private, Nonprofit organization
Learning Objectives Discover 5 advantages to using a trauma informed approach over a relapse prevention model when working with clients with sexual issues. Learn how to formulate a tier system which balances the number of days that certain strict criteria need to be met in order for a client to ascend in a sexual issues program from orientation to successful discharge in as little as six months. Analyze collected observational data to identify and develop six specific core skill sets that clients with sexual issues are missing
Exercise Cold and Calculating No Empathy Master Manipulator Sex Addict Grooming Highly Dangerous Preys on Others Violent 11 year old Referral
Previous Approach to Treatment In past treatment at KidsPeace approach utilized the Relapse Prevention Model of care Sexual Behaviors Main Focus of Treatment Avoidance/Detouring to keep from re-offending Focus on client as offender rather than victim Less concern related to connection between trauma and current behaviors
What We Were Finding Average length of stay 14+ Months Self-Identification of Monsters Minimal to no investment for overall change Discharge plans to a lower level of care Acuity of Non-Sexual Behavior on BPRS-C
Brief Psychiatric Rating Scale for Children (BPRS-C) The Brief Psychiatric Rating Scale for Children (BPRS-C) is a multidimensional rating scale consisting of 21 symptoms and behaviors, each of which is rated for severity on a 7- point scale from not present to extremely severe. Each of the 7 scales includes three items. The scales are: Behavioral Problems, Depression, Thinking Disturbance, Psychomotor Excitation, Withdrawal Retardation, Anxiety, and Organicity. These scales combine into one overall Total Score This tool is used to measure psychiatric symptoms such as depression, anxiety, hallucinations and unusual behavior The tool is administered at admission, at least every 90 days after and at discharge
Acuity Change on Admission between 2012-2014 and 2015+ Sexual Issues Program 2012-2014 Average Acuity Score 2015+ Average Acuity Score 5.00 4.97 4.50 4.42 4.00 3.50 3.83 3.00 2.79 2.50 2.57 2.96 2.00 2.21 1.50 1.42 1.84 1.00 0.91 0.50 0.00 Behavioral Problems Thinking Disturbance Psychomotor Excitation Anxiety Total
What We Began to Examine Connection with developmental trauma Trauma reenactment vs. purposeful sexual offense Power of labels Correlation with Family/Support Investment Post Discharge Can adult treatment be the same for Juveniles
Alternative Approach to Treatment By end of 2014, New treatment approach geared towards Trauma Informed Care Sexual Behaviors are a symptom of larger struggles, and need holistic approach Focus on client as victim rather than offender Identification of impact of Trauma
Paradigm Shift Trauma Informed Care Shifts the Question from What s wrong with you? to What happened to you?
Goals of the Redesigned Program Decrease overall length of stay from approximately 14+ months to 8-11 Months and in as little as 6 months. Younger Ages Build self esteem through empowerment Utilize a strength based and trauma informed model to create internal changes to show longer lasting impact Utilize data driven interventions to establish progression of treatment.
Clinical Focus Specific skill sets were developed that were based on observational data of deficiencies that most clients in Sexual Issues houses were missing. All of clinical leadership have become or are in process of becoming Nationally Certified Trauma Therapists (TF-CBT)
Clinical Training Training for Clinicians on specific evidence based interventions: Individual Therapy Modalities Trauma Focused-Cognitive Behavior Therapy (Foundation) Cognitive Behavior Therapy Applied Behavioral Analysis DBT Skills Family Therapy Modalities Parent Management Training Eco Systemic Family Therapy
TF-CBT acronym PRACTICE Psychoeducation/Parent Training about childhood trauma and PTSD Relaxation skills individualized to the child and parent Affective modulation skills adapted to the child, family, and culture Cognitive coping: connecting thoughts, feelings, and behaviors related to the trauma Trauma narrative: assisting the child in sharing a verbal, written, or artistic narrative about the trauma(s) and related experiences, and cognitive and affective processing of the trauma experiences In vivo exposure and mastery of trauma reminders if appropriate Conjoint parent-child sessions to practice skills and enhance trauma-related discussions Enhancing future personal safety and enhancing optimal developmental trajectory through providing safety and social skills training as needed
Treatment Planning Focus on Measurability and Clinical Data use in treatment plans. Use the tools: Scorecard and BPRS-C Data to inform decision making. Targeted interventions to attempt community reintegration as first priority in discharge planning.
Change in Program Structure Based on building on strengths and reinforcement. Increase number of to 5 and lower number of days between Include real world, reinforcement opportunities, including Point Store, Life Skills, Community Service Change in Companion Workbooks Stages of Accomplishment By Dr. Phil Rich
Six Core Skills Behavioral Observation and Data Collection lead to the identification of 6 core skills, that we felt would help holistically treat the client while simultaneously get them closer to reintegration back into the community.
Emotional Expression/Regulation
Emotional Expression/Regulation Emotion Regulation Scale Jim s coping skills: External - take a time out, go for a walk, play gameboy, talk to staff, appropriate drawings Internal - deep breathes, count to 10 1 2 3 4 5 6 7 8 9 10 Calm Calmly talk to others Ask questions Respectful Follow expectations Low energy level In Control Low need for coping skills Frustrated/Agitated/Hyper Arguing Making Demands/Impatient Not Following Expectations Consequences More energy Not as in control More need for coping skills Crisis/Angry Out of Control Yelling, Screaming Punching Kicking Damaging objects Restrained Unable to use coping skills well
Comprehension of Normal Development of Human Sexuality Puberty Relationships Sex Body Image Masturbation
Social Relational Skill Building and Interpersonal Development Self
Then Now
Problem Solving and Coping with Impulsivity
Problem Solving and Coping with Impulsivity Imagine giving a group of elderly people a cell phone and telling them to text a friend
Empathy
Personal Accountability and Internalization Recognize situational, emotional, and cognitive factors that might contribute to a reemergence of inappropriate behaviors Identification of connection (trauma to choices) Methods to avoid high-risk situations Demonstrate appropriate community reintegration skills.
Case Study 16 year old client male client admitted June of 2015. Referred due to consistent and inappropriate sexual acting out behaviors in the home Excessive masturbation towards family Addictive pornography viewing including stealing to purchase from the internet and building locks to keep out family from room or computer Sexual threats towards others in community Additionally combative and aggressive in the home toward his elderly parents, which included physical aggression, firesetting, and cruelty to animals.
Case Study Hx of multiple inpatient hospitalizations due to self-harm and suicidal ideation and attempts. Successfully discharged December of 2015 (approximately 6 months after admission) to the home Family, was confident that treatment significantly lessened the risk of recidivism, and felt his previous aggressive, unsafe, and concerning behaviors were able to be managed in the home.
Case Study BPRS-C Results Anxiety 29% Symptom Reduction Withdrawal/Isolation 50% Symptom Reduction Psychomotor Excitation 14% Symptom Reduction Admisson Discharge Thinking Disturbance 100% Symptom Reduction Depression 36% Symptom Reduction 55% Symptom Reduction Behavioral Problems
Progress Monitoring Individualized Score Cards Graphing Capabilities Brief-Psychiatric Rating Scales for Children (BPRS-C) Individual and Program Reviews Client High Risk Behaviors Clinical Treatment Benchmarks Discharge Disposition Length of Stay Addition starting in 2017 Juvenile Risk Assessment Tool (J-RAT)
Scorecard
Sexual Issues Program Length of Stay 450 400 350 300 250 200 150 100 50 0 Pre Post Mean 424 316 Median 435 337
Percent of Symptom Improvement Using Pre-Post BPRS-C Sexual Issues Program 2012-2014 2015-70% 61% 60% 50% 40% 42% 39% 30% 29% 29% 20% 14% 17% 19% 10% 8% 7% 0% Behavioral Problems Thinking Disturbance Psychomotor Excitation Anxiety Total
Behavior Improvement 45% 43% 42% % Improvement Restraint Rate Client to Staff Aggresssion Client to Client Aggression
Client's Discharged Home 2012-2014 2015- Series1 34% 67%
Barriers to Program Completion Delay of the client to embrace the new treatment approach. Previous unknown traumatic events. Family Investment Insurance Time Frames (what is medical necessity?)
Goals of the Redesigned Program Decrease overall length of stay from approximately 14+ months to 8-11 Months and in as little as 6 months. Build self esteem through empowerment Utilize a strength based and trauma informed model to create internal changes to show longer lasting impact Utilize data driven interventions to establish progression of treatment.
It took me a long time to believe there were people in the world that would want to help me without wanting something in return. In that life, everything has a price and everybody wants something for what they give you. I m learning now as an adult that s not the truth. There are good people out there doing good things just for you without wanting anything in return. Source: http://www.houstonchronicle.com/local/gray-matters/article/trafficking-q-a-5994616.php
Journal References Child Welfare Information Gateway. (2012). Trauma-focused cognitive behavioral therapy for children affected by sexual abuse or trauma. Washington, DC: U.S. Department of Health and Human Services, Children s Bureau. Creeden K. (2013). Taking a Developmental Approach to Treating Juvenile Sexual Behavior Problems. International Journal of Behavioral Consultation and Therap. 8(3/4): 12-16. D Orazio M.D. (2013). Lessons Learned from History and Experience: Five Simple Ways to Improve the Efficacy of Sexual Offender Treatment. International Journal of Behavioral Consultation and Therap. 8(3/4): 2-7. Letourneau, E.J., Borduin C. M. (2008). The Effective Treatment of Juveniles Who Sexually Offend: An Ethical Imperative. Ethics Behav. 18(2/3): 286-306. doi 10.1080/1050842080206694. Steinfeld, B., Scott, J., Vilander, G., Marx, L., Quirk, M., Lindberg, J., & Koerner, K. ( 2015). The Role of Lean Process Improvement in Implementation of Evidence-Based Practices in Behavioral Health Care. The Journal of Behavioral Health Services & Research : Official Publication of the National Council for Behavioral Health, 42, 4, 504-518. Zelechoski, A. D., Sharma R., Beserra K., Miguel J. L., DeMarco M., Spinazzola J. (2013) Traumatized Youth in Residential Treatment Settings: Prevalence, Clinical Presentation, Treatment, and Policy Implications. Journal of Family Violence.
Questions
Contact Information If you have additional of future questions about the workshop: Dominick DiSalvo, Sr. Director of Clinical Services Phone: 610-799-7953 Email: dominick.disalvo@kidspeace.org