ab presentation

integrating AOD and

mental health work

with young people

Talking Point May 2013

A framework for resilience based intervention

2013

Andrew Bruun

Director of Research, Education, Advocacy & Practice YSAS

M: 0407 310 344

[email protected]

mailto:[email protected]

Vulnerability

All young people are vulnerable to

disruptions and challenges during the

transition from childhood to adulthood.

Vulnerability becomes problematic when

negative behaviours or experiences

multiply and there are few or no supports

in place to assist young people.

The individual developmental, social &

environmental context in which young

people grow up can mean they confront

issues that they do not have the skills,

knowledge or support to get through.

Layers of vulnerability

Positive Adaptation: Developmental regulation

Positive adaptation, through regulated exposure to adversity

involves a developmental progression, such that new

vulnerabilities and/or strengths often emerge with changing life

circumstances

Developmental problems arise when children and young

people are not exposed to enough adversity and risk, or so

much that it is impossible to overcome

Masten, A. S., Obradovi, J. & Burt, K. B. (2006). Resilience in emerging adulthood: Developmental perspectives on continuity

and transformation. In J. J. Arnett & J. L. Tanner (Eds.), Emerging adults in America: Coming of age in the 21st century (pp.

173–190). Washington, DC: American Psychological Association Press.

Common protective factors

(development & resilience)

Effective parents and caregivers

Connections to other competent and caring adults

Problem-solving skills

Self-regulation skills

Positive beliefs about the self

Beliefs that life has meaning

Spirituality, faith and religious affiliations

Socioeconomic advantages

Pro-social, competent peers and friends

Effective teachers and schools

Safe and effective communities

Protective systems

Human attachment system (beginning with primary care givers and expanding with development to include families, peers and significant others)

The human intelligence and information processing system (a human brain in good working order)

The mastery / motivation system (motivation to adapt and opportunities for agency)

The self-regulation system (Self-control and emotion regulation)

Religious and cultural systems

School and community based systems

Protective systems

• “The greatest threats to young people occur when these key systems and the capacity they represent are damaged or destroyed and never restored. Nurturing, supporting, and restoring these fundamental adaptive systems for human development are top priorities for promoting competence or resilience in young people and preparing them to weather the storms of life”

Masten, A. (2009) Ordinary magic: Lessons from research on resilience in human development (p32).

Past or current issues and

adverse experiences

Abuse (physical, sexual, emotional) and neglect

Exposure to violence (domestic and other)

Excessive family conflict and/or breakdown

Complicated grief

Physical health complaints (particularly involving

persistent pain)

Academic failure and tenuous school connection or premature disconnection

Past or current issues and

adverse experiences (cont)

Adverse experiences are often the source of significant trauma and can result in:

Insecurity and a compromised sense of safety

A sense of powerlessness, hopelessness and fear.

Damaged self-concept and feelings of shame, guilt and rage.

Difficulties in regulating impulses and emotions increasing the likelihood of:

• Disrupted and conflicted relationships with significant others

• Reduced participation and social exclusion

An accumulation of adverse experiences (developmentally and/or in a short timeframe) can contribute to a range of health and behavioural problems:

Substance use problems

Mental illness and a range of mental health problems

Problems with anger and aggression

An antisocial orientation and offending behaviour

Self-injury

Persistent suicidality

issues and conditions

Complexity and vulnerability

Complexity The number adverse experiences or problems

Etiology & severity or each adverse experience or problem

The extent to which particular problems are either highly advanced or in an early stage of development

Whether problems cluster together to intensify the risk of harm or reinforce each other to form long-term, negative chain effects that can entrench health and behavioural problems.

Determining vulnerability: Requires investigation of the young person’s developmental stage and an

analysis of the nature and quality of the resources and assets that can be

mobilised to deal effectively with the adversities he or she has to contend

with.

Resilience

The same factors that interact to foster and protect healthy

development and optimal functioning also support resilience.

All young people can develop their capacity to be resilient

given the right conditions

Johnson, B. & Howard, S. (2007) Causal chain effects and turning points in young people’s lives: a resilience perspective.

Journal of Student Wellbeing, Vol. 1, No. 2, pp. 1-15.

“Resilience is not only an individual's capacity to overcome

adversity, but the capacity of the individual's environment to

provide access to health-enhancing resources in culturally

relevant ways.”

Ungar, M. (2005) A Thicker Description of Resilience. International Journal of Narrative Therapy and Community Work, 3 & 4,

89-95.

Resilience

Resilience is not an intrinsic trait but a dynamic process

occurring under specific circumstances - It is never an across

the board phenomenon and no young person is invulnerable.

Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227-238.

There are huge individual differences in young people’s

exposure to the ‘bad’ experiences that constitute environmental

risks.

Harvey, J. & Delfabbro P. H. (2004) Psychological resilience in disadvantaged youth: A critical overview. Australian

Psychologist, March; 39(1): 3 – 13

Hidden Resilience

The experience of disadvantage and social exclusion means

that not all young people have access to useful and necessary

resources and assets that most young people might take for

granted (Johnston and Howard, 2007).

Negative social discourses characterising young people with

substance use as delinquent, disordered, dangerous or deviant

can mask their strengths and efforts to meet their needs.

Ungar, M. (2005). A Thicker Description of Resilience. International Journal of Narrative Therapy and Community Work, 3 and

4, 89-95.

Resilience based practice

Intention:

To create the conditions that enable young people to

gain as much control as possible over their own health

and well being

This involves young people and those involved in

their care having access to resources and assets that make it possible for them to meet their needs, fulfil their aspirations, and respond effectively to environmental influences (to adapt).

Resilience based practice

Five key domains of need:

Protection from harm and the capacity to respond to crisis (safety)

Stability and the capacity to meet basic needs

Opportunities for participation and constructive activity (education, work, recreation, etc)

Developmentally conducive connections (people, culture, places)

Greater control of health compromising issues and behaviours (e.g. harmful substance use, mental health problems, homelessness, offending, etc)

Constructive

Participation

• Educational

• Vocational

• Recreational

• Community

Developmentally

conducive

Connections

• Family & Sig other

• Culture

• Place

Resilience framework

Co-occurring

health

compromising

issues and

behaviours

•Substance

misuse

•Mental health

problems

•Disconnection

from school and

work

•Homelessness

•Complex grief

•Trauma (PTSD)

•Anti-social /

offending

behaviour

Stability &

Basic needs

• Safe and

comfortable

spaces where

young person

feels connected,

welcome

• Adequate

housing with

certainty of tenure

• Income

•Regulated

experience

(constructive limit

setting)

Crisis &

Immediate

Risk

• Protection

from harm

•The capacity to

deal effectively

with issues that

are causing (or

have the

potential to

cause) harm

and jeopardize

safety

Evidence

Based/

Therapeutic

Interventions

Social Ecology:

Resources

•Material

•People

•Socio-cultural

•Health / community

Skills / Knowl /

Attributes

•Living skills

•Self management

•Interpersonal skills

•Cultural competence

Beliefs/Values/

Identity

•Self concept /world

view

•Meaning making

Ph

ys

ica

l &

So

cia

l C

ap

ita

l C

ult

ura

l &

hu

ma

n c

ap

ita

l

Resilience based practice (RBP)

Young people with the right mix of opportunity, motivation and

resources can move beyond defensive coping into adjustment and

positive adaptation.

Practitioners seek to protect and nurture a young person’s capacity to

be resilient by altering exposure to risk, influencing the experience of

risk, averting chain reactions of negative experience and fostering

healthy adaptation and growth.

Well-timed interventions geared to respond at critical moments, have

the potential to disrupt negative cascading effects or initiate healthy

developmental processes and positive adaptation.

Masten, A. (2009) Ordinary magic: Lessons from research on resilience in human development

Ungar, J. (2011). Counseling in Challenging Contexts: Working with individuals and families across clinical and

community settings. California: Brooks/Cole.

AOD needs identification &

service planning model

•3 or more different drugs

used in the last 4 weeks (ex.

Tobacco)

•Daily/Almost Daily use of at

least 1 drug in the last 4

weeks (ex. Tobacco)

•Meets criteria for substance

dependence

•Ever injected any drug

•Involvement in substance

related risk behaviours and

the experience of harm

AO

D S

everi

ty

Vulnerability/Life complexity

Typical

complexity for age

N

ot u

sin

g L

ow

H

igh

Se

ve

re

Additional

Complexity

High Extreme

AOD

Severity Indicators



•Acute housing problems (last 4

weeks)

•Not involved in education or work

(last 4 weeks)

•Conflict with family or relatives (last

4 weeks)

•Not satisfied with physical health

•Moderate or High emotional

distress (last 4 weeks)

•Current offending or involved in

criminal justice system (ever)

•Formal diagnosis of mental health

condition (ever)

•Attempted suicide or self harmed

(ever)

•Experience of abuse and neglect or

child protection involvement (ever)

AO

D S

everi

ty


Typical

complexity for age

N

ot u

sin

g L

ow

H

igh

Se

ve

re

Additional

Complexity

High Extreme

Complexity

Indicators



•Severe and high risk AOD

use interrelated with

characteristics of high to

extreme vulnerability

•Need interrelated AOD

problems and complexity

addressed simultaneously

by a range of

interventions

AO

D S

everi

ty


Typical

complexity for age

N

ot u

sin

g L

ow

H

igh

Se

ve

re

Additional

Complexity

High Extreme

Service required



•Low level or emerging

AOD use combined with

3 or more characteristics

of high to extreme

vulnerability (see above:

Cohort 1)

•Often younger but at

serious risk of AOD

problems developing

and escalating

•Need early

intervention to prevent

transition to cohort 1

(entrenched harmful

AOD use)

AO

D S

everi

ty


Typical

complexity for age

N

ot u

sin

g L

ow

H

igh

Se

ve

re

Additional

Complexity

High Extreme

Service

required



Serious AOD problem

combined with 1 or 2

indicators of additional

complexity

•Retains connection with

family, school, employment,

constructive activity

• Stable living circumstances

• Little or no involvement with

health and welfare services

Need AOD specific

intervention and early

intervention to maintain

connectedness and

participation (prevent

transition to cohort 1)

AO

D S

everi

ty


Typical

complexity for age

N

ot u

sin

g L

ow

H

igh

Se

ve

re

Additional

Complexity

High Extreme

Service

required

Modalities and interventions

Outreach: Modality

Description

• Flexible and responsive medium for connecting with and delivering

services to hard to reach groups. Can offer services in environments

where young people congregate and/or feel comfortable. Invloves

care and recovery co-ordination and timely interventions.

Objectives:

• Locate and connect with targeted young people

• Provide therapeutic interventions according to need and readiness of

young people and context

• Care and recovery co-ordination

Outreach: Interventions

• Service promotion & case finding

• Assertive engagement

• Case work (including assessment & individualised care

planning)

• Liaison & advocacy

• Health education & health promotion

• Foundational counselling

• Behavioural & other psychosocial interventions

• Family support

• Home-based withdrawal

• Secondary consultation to other services

Clinical: Modality

Description

• Sessional services are currently provided within youth AOD services

on the basis of 1-2 hour appointments (e.g. counselling), or as brief

consultations. Suitable where life complexity and vulnerability are in

check – suitable for AOD specific counseling and family focused

interventions

Objectives:

• Offer the types of specialist interventions that are potentially best

provided in a clinic based setting (see next slide)

Clinical: Interventions

• AOD counselling (employing EB therapeutic models)

• Pharmacotherapy

• Specialist mental health care for a range of serious mental

health problems including: major depression, PTSD, other

anxiety disorders, bipolar disorder, psychotic illnesses

• Family therapy

• Grief and loss counselling

• Sexual assault counselling

• Medical care

Day program: Modality

Description

• Day Programs provide safe, stimulating and flexible environments that

young people can access in their own time and to the extent that they

desire.

Objectives:

• To offer a wide range of resources, programs and services that

motivate, encourage and support young people to move away from

problematic behaviours and contexts, towards more stable and

healthy lifestyle.

Day Program: Interventions

• A safe place to spend time /

respite

• Supervised or monitored recovery

• Primary health care

• Personal care facilities

• Health education

• Life skills programming

• Motivational interviewing


• Behavioural & other

psychosocial interventions

• Peer support

• Supported referral and

linkages

• Activity based therapeutic

programming

• Secondary consultation to

other services

Youth Residential Withdrawal: Modality

Description

• Structured environment providing up to two weeks (or more) of safe,

AOD free, age appropriate accommodation in a unit that is

continuously staffed.

Objectives:

• Stabilise of client’s mental and physical health and increase access

to ongoing care

• Break the escalating cycle of AOD dependence and high risk

behaviour

• Build pro-social connections to support longer term behaviour

change

Youth Residential Withdrawal: Interventions

• Comprehensive primary health care

• Medically supervised AOD withdrawal & pharmacotherapy

• Health education

• Mental health care

• Integrated psycho-social care planning (co-ordinated with other

services)


Residential rehabiitation: Modality

Description

• Long term residential rehabilitation geographically separate from

community of origin. Provision of a holding environment - a physically

and emotionally safe place to live and grow. Common to employ a

therapeutic community model

Objectives:

• To provides a safe, stable, and structured environment within which

young people can be assisted to secure and develop a diverse range

of resources and assets needed for resilience and to learn to live in

the world without needing to turn to alcohol and other drugs for

answers.

Residential Rehabilitation: Interventions

• Community as therapeutic vehicle

• Primary health care and health education

• Activity based therapeutic programming

• Life skills programming




• Peer support

• Supported referral and linkages


Supported accommodation: Modality

Description

• Provision of structured community based accommodation in which

young people are provided with a range of supports while living

independently or semi-independently.

Objectives:

• To provide a long term safe stable living environment and the support

required to develop personally and build the diverse range of

resources and assets needed for resilience and to live well without

resorting to misuse of alcohol and other drugs.

Supported accommodation: Interventions

• Assessment and therapeutic care planning

• Medical care and Health education

• Education and vocational transitions




• Family focussed interventions

• Peer support

• Supported referral and linkages


Maximum security prison

War zone

Youth

service A

Youth

service B

Systematisation & Compassion

Un

stru

ctu

red

St

ruct

ure

d

Compassion

Syst

em

isat

ion

Alienation Person Centred

ab presentation

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