FACT FOR MINORS The Therapy Unit of Els Til.lers Educative Center Barcelona, May 2017 Oriol Canalias ocanalias@pssjd.org Maria Ribas mribas@pssjd.org Noemí del Prado ndelprado@pssjd.org
The Therapy Unit of Els Til.lers Educative Center Young offenders between 14 21 years old. Mental health and/or addictions. 12 beds
5481 young offenders in Catalonia (2016). 8.6% in CE (N = 474) 4.- C.E. Montilivi 6.- C.E. Alzina 7.- C.E. Els Til.lers 1.- C.E. El Segre 2.- C.E. Oriol Badia 3.- C.E. Folch i Torres 5.- C.E. Can Llupia UNITAT TERAPÈUTICA DE JUSTICIA JUVENIL PARC SANITARI SANT JOAN DE DEU, SSM. CSMIJ / CSMA / CAS / FHSP CLAVER
JJTU is a sanitari resource specialised on Mental Health problems and substance addictions, focused on complex pathologies and antisocial conflicts prevention, evaluation, treatment and recovery Multidisciplinary and intensive approach focused on community care, considering risk assessment of clinical and legal recidivism Involving patient and family and social context. Cooperation and Willingness are the clues to develop a positive process.
UTJJ Goals Complete diagnostic assessment: psychiatric and psychological diagnosis with complementary proves Specialised and intensive therapeutic intervention Intensive nursing care with an individual care managament. Improve treatment adherence with psychoeducational programs. Group and individual psychotherapy, working as a therapeutic community. Based on a bio-psycho-social model with a multidisciplinary team that develops an Individual Therapeutic Programm (PTI). Priority to Social Reintegration (693 permits)
Multidiscisplinary team 2 psychiatrists 2 psychologists 1 Social Worker 1 Doctor 8 Mental Health Instructors 4 Community Workers 6 Nurses 2 Nursing Assistant 1 Nursing Supervisor 1 Clinical Psychologist Supervisor 28 Professionals
Juvenile Justice Population Especifities Multiproblematic youngs Psychopathogical gravity: dual pathology, high impulsivity, defiant attitudes, etc. Important difficulties to mentalize conflicts Social Vulnerability Gravity of recieved and implemented abuse, they reject the adult Specific needs thar require interdisciplinar and multidepartamental interventions Social context frequently precarious, negligent and little support Neurological Vulnerability Psychiatric Vulnerability
Juvenile Justice Therapy Unit I. Inclusion criteria: Therapeutic measures Diagnostic evaluation Seriousness criteria II. Exclusion criteria: Crisis (acute decompensation) Lack of patient s willingness
Therapeutic Juvenile Justice Unit I. 12 patients (14-21 years). MIXED. There are currently 9 boys and 3 girl. II. Average age: 17 a. III. Current Diagnoses: 70% dual pathology, 50% three diagnoses 9% 18% 9% ADHD PSYCHOSIS 28% SCHIZOPHRENIA 18% 9% 9% BIPOLAR D AUTISM SPECTRUM D AFECTIVE D SUBSTANCE D
2006-2014 BIOLOGICAL FACTORS 12% Drug Addicted Mother 6% Mental Retarded Mother 1% Genetic Alterations 32% Intellectual Disability 20% Psychotic Spectrum PSYCHOLOGICAL FACTORS 51% Toxics 36% Personality D. 52% Psychological Abuse 27% Physical Abuse 7 % Sexual Abuse SOCIAL FACTORS 18% Antisocial Familia 19% Death Father 57% Parent Divorce 37% Inmigrants (20% Moroccan) ANTI-SOCIAL BEHAVIOUR 37% Robbery with coercion 18% Robbery with injuries 28% Familiar Abuse 9% Attempted Murder 3% Sexual Abuse N=251
Psicoeducative Programm Nurse and Educational Team specialised on Mental Health and Addictions head the following activities: Health and Daily Living Activities Education Program: relaxation, medication, etc. to improve the autonomy Social Skills Program: Social skills and solving conflicts. Cultural and Leisure Program: Leisure activities, community involvement and social participation, etc. Job Training Program: Pre-working activities and job seeking Education Program: Lead by the Department of Education Social Reintegration Program: educative, family, therapeutic and working outings. Lead by the multidisciplinary team
Therapeutic Programm Incipient Psychosis Program: Differential diagnosis with psychosis caused by toxics, early intervention to reduce severity and psycho-education to improve treatment adherence Schizophrenia, Psychosis and Affective Disorders Program: Treatment adherence and early detection of cognitive damage. Personality Disorders Program (Borderline and Antisocial Personality Disorder): Early detection of abnormal personality traits and treatment establishment in case it is possible to diagnose Substance Addictions Program: Detox and pharmacological treatment when craving symptoms. Motivational approach, psychoeducation and risk situation detection, promoting relapse prevention and to achieve abstinence. Family and social counselling. ADHD Program: Differential diagnosis with or without hyperactivity. Pharmacological treatment when it is effective and internal control when it is not. Individual and familiar psychoeducation because of the serious behavioural problems
Therapeutic Attitude Professional team should be stable, reliable, coherent, firm EMOTIONAL ADULT Has to be the containing setting for the aggressiveness, establishing limits and improving comprehension and emotional recognition at the time. COMMUNICATIVE VALUE OF THE ACTING OUT : connecting behaviours and internal world HERE AND NOW interventions are more effective, focusing on the transference. Be aware of countertransference. Therapist needs to have low expectation, frustration tolerance and improve patient abilities and development
Care model BIOPSYCHOSOCIAL PARADIGM THERAPISTS COTHERAPISTS MULTIDISCIPLINARY TEAM PSYCHODYNAMIC COMPRENHENSION THERAPIES: PSYCHODYNAMIC SYSTEMIC COGNITIVE- BEHAVIORAL THERAPEUTIC COMMUNITY
Theoretical Background Biopsychosocial Corrective emotional experience Multidisciplinary Psychological Resilience Bronfenbrenner Ecological Systems Theory Attachment Theory
Bronfenbrenner Ecological Systems Theory Microsystem: institutions and groups that most immediately and directly impact the child's development Mesosystem: Interconnections between the microsystems Exosystem: links between a social setting in which the individual does not have an active role and the individual's immediate context Macrosystem: Describes the culture in which individuals live Chronosystem: The patterning of environmental events and transitions over the life course, as well as sociohistorical circumstances
Attachment Theory Attachment Theory Relationship with at least one primary caregiver for the successful social and emotional development Psychological Resilience Individual's ability to successfully adapt to life tasks in the face of social disadvantage or highly adverse conditions Corrective Emotional Experience In the face of the emotional conflicts of the patient, the therapist reacts in a different way than the people who were present in the past. Classification: secure, anxious-ambivalent, anxious-avoidant, and disorganized 1.Ability to make realistic plans and taking steps to follow 2.Positive self-concept and confidence in one s strengths 3.Communication and problem-solving skills 4.Ability to manage strong impulses and feelings Nothing works The young delinquent becomes bad because he is defined as bad
"If you take people for what they are, you will make them worse than they are. If you take them for what they can become, you will help them to get where they should be taken. Franz Alexander
Research on Recidivism Maria Ribas et al. in collaboration with the Centro de Estudios Jurídicos Patients interned in the Unit between 2010 and 2013 81 Patients Average follow-up 4.5 years First results: Profile: Spanish guy, 16 years old, with an average socioeconomic level and at secondary school Main risk factors are: Low academic performance, stress, inability to cope, impulsivity, difficulty managing anger and participation in previous violent acts. At an historical level, exposure to violence at home and physical and psychological abuse Protection factors are: strong attachment to a prosocial adult and peer group without antisocial behaviors The risk for violence in UT patients is HIGH Recidivism is 51.9%. More frequent during the first 6 months
Research on Recidivism DIAGNOSIS %RECIDIVISM CHARACTERISTICS SEVERE MENTAL DISORDER 60 Non-violent offenses. No prosocial adult and family psyquiatric background TOXIC-SUBSTANCE RELATED DISORDER 53.2 Peers delinquency, poor educational skills of the parents, poverty, delinquency and violence, no prosocial activities and physical abuse. MILD MENTAL RETARDATION 51.9 Drug and alcohol abuse DUAL PATHOLOGY 48.5 the most violent. Early onset of violence. Peers group delinquency. Context of poverty, delinquency and violence MENTAL DISORDER 43.2 Very high stress coping problems, high socioeconomic level BEHAVIORAL DISORDER 41.7 Non-violent crimes ADHD 35 Family disapproval of violent behavior. Less divorce. Peers group delinquency. Most frequent dual pathology
UT vs Juvenile Justice population Less judicial records Less participation in non-violent crimes before internment Internment shorter than 6 months Low peers delinquency Adults offering emotional support Low family delinquency and family disapproval of it Social support and low levels of poverty and/or delinquency Difficulty responding in a nonaggressive way External locus control High impulsivity, difficulty in managing anger, concentration problems, hyperactivity and low academic interest HIGH RISK to commit a violent crime, to show a violent behavior during internment and permits. The risk in the educative center general population is LOW However, no significant differences in percentage of recidivism, although UT population commit more violent offenses. The percentage of compliance during permits is 95%. Only 27.2% had a therapeutic internment measure
Conclusions It is necessary to do a follow-up It is necessary to have specialized units for this specific population There is a difficulty when evaluating mental health problems in juvenile offenders Community reintegration doesn t increase recidivism
Post-Discharge Follow-Up Importance is the positive therapeutic relationship Actions designed to consolidate the clinical improvement made in the community setting, so as to avoid criminal recidivism Post-discharge follow-up program of six months duration Research about adherence to treatment and recidivism
Methodology The psychiatrist and/or psychologist attending the minor will carry out: Two weeks individual interviews for the first two months after the end of internment. monthly follow-up to 6 months. coordination with the family. The social worker will carry out coordination with : the DAM. the professionals from the community mental health and addictions network. the job training units where the minors are enrolled. the family. All of the information will be collected through questionnaires designed especially for this community follow-up. Informed consent will be required 24
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