The Integration of Treatment with a Specialist Residential Service for Young People who have Sexually Harmed/Abused – Diane Curran and Linda Cooney
At the NOTA Annual Conference in Belfast in 2018, our workshop focused on providing an example of the benefits of integrating specialist treatment with residential child-care services for young people who have sexually harmed / abused. Both presenters continue to be involved in the development and on-going implementation of this service.
What an Experience!
Delivering this workshop at the NOTA Conference initially seemed a daunting prospect, however was overall experienced as a thoroughly enjoyable opportunity. We felt lucky to share our learning with engaged colleagues whose comments and contributions have helped us in our continual development of ideas and thinking. The fact that this remains an evolving area for development in the field is both exciting and rewarding and we both thank attendees for enriching our own learning.
The workshop covered these main areas:
- Why specialist residential provision is needed for a cohort of young people who have sexually harmed / abused.
- The advantages of a specialist residential programme
- The Integrated Residential Treatment Plan (IRTP).What more needs to be done to develop this service?
Why specialist residential provision is needed for this Population
1) Historic context
Historically there has been a cohort of young people whose needs existing systems and the diverse contexts within residential child care have struggled to meet. Young people who have sexually harmed often require a more specialist level of input and support. However as there has been a lack of services available to them locally, this has resulted in some young people being placed in care out of their country of origin for accommodation and specific treatment. This practice has created a number of challenges in relation to maintaining optimal contact between young people, family and community; providing treatment to young people in isolation from their families/care-givers due to distance; and, reintegration of young people back to their community post treatment.
2) Alternative Care
Removal from home into specialist residential care is rarely needed due to harmful sexual behaviour (HSB) alone. The majority of young people and adolescents who have exhibited HSB can be supported and treated within the existing family/community or within mainstream alternative care settings. In certain circumstances, however, these are not appropriate or effective.
Community based treatment programmes require the young person to have stability, safety and support so as to effectively engage the young person. Unfortunately, the families and communities of some young people may not allow for this. Factors that impact on the stability, safety and support for a young person include:
- The ability of caregiver/s to supervise and safely manage a young person in the home;
- the young person’s responsiveness to caregiver intervention;
- the needs and responses of sibling/s and other affected children;
- other risk factors present, e.g., impulse control and risk to community;
- persistence of behaviour despite interventions; and,
- developmental issues, mental health and other diagnoses that may warrant a ‘bespoke’ treatment plan.
3) Profiles of Young People in Alternative Care
Equally, mixing the profiles of young people with a complexity of needs within a mainstream residential setting does not always facilitate effective treatment of harmful sexual behaviours and in some cases may place other young people at potential harm/risk. Balancing the needs and confidentiality of the mixed profile of young people can present the following challenges:
- It requires a level of ‘secrecy’ that can allow a young person to maintain a ‘position of denial’ in respect of their harmful sexual behaviours;
- issues of shame and isolation for the young person can exist;
- staff do not generally have specialist training in a mainstream residential centre.
The advantages of specialist residential Programme
Recent evidence-based frameworks highlight what principles and best practice approaches in the treatment of HSB should include (Hackett et al, 2019). The key themes arising are that specialised services need to be holistic, co-ordinated, inclusive of family/significant others, and developmentally appropriate. Programmes should be informed by a comprehensive assessment and avail of a ‘toolbox of approaches’. They should avoid manualised approaches and non-directive therapeutic approaches.
The presenters outlined aspects of their specialist residential treatment centre’s provisions which encompass:
- Care programmes that consider the physical, social, emotional, educational and cultural wellbeing of the young person alongside treatment for harmful sexual behaviours.
- Individualised assessments and integrated residential treatment programmes (IRTP) that take account of the young person’s developmental stage, developmental difficulties and experiences of trauma.
- A treatment programme which is delivered through a variety of mediums and staff members which allows for daily layered ‘treatment contact’.
- The families/significant others are involved from the outset of treatment and there is specific family link work undertaken with them so families understand the programme, reinforce messages with the young person, and address their own issues and the impact of the HSB on them. Whilst this is ideal, a lack of family participation does not exclude working with a young person.
- Safety in the community that is addressed through individualised safety plans which are progressively developed as the young person goes through the treatment programme. This is achieved via a high level of supervision and support by the team.
- Issues of secrecy, shame and denial which are addressed through an ethos of openness and respect while maintaining an awareness of risk and confidentiality. This aims to build safety for the young person to allow them to address concerns while also enhancing their strengths.
A key strength of the programme is that the staff team are specifically trained in understanding HSB and in the provision of treatment elements of the programme. This allows for any staff member to provide treatment to the young person, according the nature and quality of their relationship, rather than this being confined to certain professionals within the centre.
The Integrated Residential Treatment Plan (IRTP)
Treatment modality is integrated and delivered via an Integrated Residential Treatment Plan(IRTP) which is planned, tailored and amended by the service to monitor common elements of specialised treatment.
1) Treatment Goals
A young person’s treatment goals are tailored to them following comprehensive assessment. There may be multiple treatment issues indicated in the assessment and the determination of which treatment issues should be addressed first and in what order is important to optimise stable, safe and effective intervention at every level of the IRTP. Whilst treatment techniques are holistic and draw on ‘no one therapeutic model over another’; it is important to be mindful of therapeutic alliances and their role in instilling hope for the young person and with their parents/carers.
2) Treatment Delivery
In order to co-ordinate the treatment effectively, different staff members/teams hold responsibility for designated treatment goals, allocated to them on a monthly basis. For example; a Keyworker or Treatment Clinician may be assisting a young person with goals to enhance their victim empathy while ‘tier 2’ residential staff utilise opportunities that may present in the centre to assist the young person with their perspective taking in the moment. In essence, the centre becomes the therapeutic environment in which every staff member has a role to play at a different tiered level of the treatment plan.
3) Rolling out the Integrated Residential Treatment Plan
The IRTP is supported by weekly and monthly handover meetings, involving the young person, the Treatment Clinician and the Key Worker. A summary of clinical information is shared and this is central to the ethos of transparency, challenging secrecy and embracing inclusion of the young person in their own treatment progress.
Separately, monthly programme meetings for each resident are held – chaired by the Centre management team, attended by all staff at the Centre, the young person’s Social Worker and other relevant professionals for example Guardian Ad Litem, Juvenile Liaison Officer, or Probation. This is where the IRTP objectives are agreed and delegated, the resident’s safety plan is reviewed.
Feedback from the young person’s self-evaluation of their progress feeds into Quarterly Treatment Reviews which are subsequently agreed with their parents/carers. This process acts to validate the treatment effort and meaningful change but also to motivate and challenge areas of need or on-going concern.
Finally, the integration infrastructure is vital to avoid therapeutic ‘drift’ and is in keeping with best practice in providing safe and transparent inputs.
What more needs to be done?
On-going development is required to constantly strive to improve the service. The presenters highlighted some of the areas they felt required further development:
1) Treatment maintaining compatibility across disciplines
The need to harness the growing compatibility across disciplines working with these young people. Seemingly conflicting positions between child protection and treatment can exist and these need to be amalgamated within frameworks, for example as with the Signs of Safety approach where the two tasks are complimentary (Turnell and Edwards, 1999). Also the conflicting messages of legal systems can reinforce the position of denial thereby potentially impacting treatment.
2) Advocacy and Education
Broadening the understanding of HSB in children / young people across a wider audience such as educators, community services, and legal systems. This should include knowledge around the low rates of recidivism thereby instilling hope that effective treatment can have positive outcomes.
3) Balance of Rights
Improving the provision of services to support young people’s transition back to the community so they can move on from treatment in a timely and supported manner. It is essential that there is a balance between the rights of these young people and the need to protect others.
4) Specialised Recruitment
Consideration to be given to specialist recruitment programmes so that staff teams choose to work with this cohort of young people and specific behaviour and have an investment in developing their specialism in this area.
We believe the continued development of the service in these ways would enhance the commitment to, and provision of, treatment to this cohort of young people.
Diane Curran, TUSLA, Children’s Residential Services
Linda Cooney, TUSLA Chartered Senior Psychologist
Hackett, S., Branigan, P. and Holmes, D. (2019) Harmful sexual behaviour framework: an evidence-informed operational framework for children and young people displaying harmful sexual behaviours. 2nd ed. London: NSPCC.
Shirk, S.R., Karver, M.S., & Brown, R. (2011). The alliance in child and adolescent psychotherapy. Psychotherapy, 48, 17-24. DOI:10.1037/a0022181
Smith, M., (2009). Rethinking Residential Child Care, Positive Perspectives. The Policy Press
Turnell, A. and Edwards, S. (1999). Signs of Safety: A safety and solution-oriented approach to child protection casework, New York: WW Norton.