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  1. 1. integrating AOD andmental health workwith young peopleTalking Point May 2013A framework for resilience based intervention2013Andrew BruunDirector of Research, Education, Advocacy & Practice YSASM: 0407 310 344abruun@ysas.org.au
  2. 2. VulnerabilityAll young people are vulnerable todisruptions and challenges during thetransition from childhood to adulthood.Vulnerability becomes problematic whennegative behaviours or experiencesmultiply and there are few or no supportsin place to assist young people.The individual developmental, social &environmental context in which youngpeople grow up can mean they confrontissues that they do not have the skills,knowledge or support to get through.
  3. 3. Layers of vulnerability
  4. 4. Positive Adaptation:Developmental regulationPositive adaptation, through regulated exposure to adversityinvolves a developmental progression, such that newvulnerabilities and/or strengths often emerge with changing lifecircumstancesDevelopmental problems arise when children and youngpeople are not exposed to enough adversity and risk, or somuch that it is impossible to overcomeMasten, A. S., Obradovi, J. & Burt, K. B. (2006). Resilience in emerging adulthood: Developmental perspectives on continuityand 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.
  5. 5. 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
  6. 6. Protective systems Human attachment system (beginning with primarycare givers and expanding with development toinclude families, peers and significant others) The human intelligence and information processingsystem (a human brain in good working order) The mastery / motivation system (motivation toadapt and opportunities for agency) The self-regulation system (Self-control andemotion regulation) Religious and cultural systems School and community based systems
  7. 7. Protective systems• “The greatest threats to young people occur when thesekey systems and the capacity they represent aredamaged or destroyed and never restored. Nurturing,supporting, and restoring these fundamental adaptivesystems for human development are top priorities forpromoting competence or resilience in young peopleand preparing them to weather the storms of life”Masten, A. (2009) Ordinary magic: Lessons from research on resilience in human development (p32).
  8. 8. Past or current issues andadverse 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 orpremature disconnection
  9. 9. Past or current issues andadverse experiences (cont)Adverse experiences are often the source of significanttrauma 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 andrage. Difficulties in regulating impulses and emotions increasingthe likelihood of:• Disrupted and conflicted relationships withsignificant others• Reduced participation and social exclusion
  10. 10. An accumulation of adverse experiences(developmentally and/or in a short timeframe) cancontribute to a range of health and behaviouralproblems: 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 suicidalityissues and conditions
  11. 11. Complexity and vulnerabilityComplexity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 inan early stage of developmentWhether problems cluster together to intensify the risk of harm orreinforce each other to form long-term, negative chain effects that canentrench health and behavioural problems.Determining vulnerability:Requires investigation of the young person’s developmental stage and ananalysis of the nature and quality of the resources and assets that can bemobilised to deal effectively with the adversities he or she has to contendwith.
  12. 12. ResilienceThe same factors that interact to foster and protect healthydevelopment and optimal functioning also support resilience.All young people can develop their capacity to be resilientgiven the right conditionsJohnson, 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 individuals capacity to overcomeadversity, but the capacity of the individuals environment toprovide access to health-enhancing resources in culturallyrelevant ways.”Ungar, M. (2005) A Thicker Description of Resilience. International Journal of Narrative Therapy and Community Work, 3 & 4,89-95.
  13. 13. ResilienceResilience is not an intrinsic trait but a dynamic processoccurring under specific circumstances - It is never an acrossthe 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’sexposure to the ‘bad’ experiences that constitute environmentalrisks.Harvey, J. & Delfabbro P. H. (2004) Psychological resilience in disadvantaged youth: A critical overview. AustralianPsychologist, March; 39(1): 3 – 13
  14. 14. Hidden ResilienceThe experience of disadvantage and social exclusion meansthat not all young people have access to useful and necessaryresources and assets that most young people might take forgranted (Johnston and Howard, 2007).Negative social discourses characterising young people withsubstance use as delinquent, disordered, dangerous or deviantcan 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 and4, 89-95.
  15. 15. Resilience based practiceIntention:To create the conditions that enable young people togain as much control as possible over their own healthand well being This involves young people and those involved intheir care having access to resources and assets thatmake it possible for them to meet their needs, fulfiltheir aspirations, and respond effectively toenvironmental influences (to adapt).
  16. 16. Resilience based practiceFive key domains of need: Protection from harm and the capacity to respond tocrisis (safety) Stability and the capacity to meet basic needs Opportunities for participation and constructiveactivity (education, work, recreation, etc) Developmentally conducive connections (people,culture, places) Greater control of health compromising issues andbehaviours (e.g. harmful substance use, mentalhealth problems, homelessness, offending, etc)
  17. 17. ConstructiveParticipation• Educational• Vocational• Recreational• CommunityDevelopmentallyconduciveConnections• Family & Sig other• Culture• PlaceResilience frameworkCo-occurringhealthcompromisingissues andbehaviours•Substancemisuse•Mental healthproblems•Disconnectionfrom school andwork•Homelessness•Complex grief•Trauma (PTSD)•Anti-social /offendingbehaviourStability &Basic needs• Safe andcomfortablespaces whereyoung personfeels connected,welcome• Adequatehousing withcertainty of tenure• Income•Regulatedexperience(constructive limitsetting)Crisis &ImmediateRisk• Protectionfrom harm•The capacity todeal effectivelywith issues thatare causing (orhave thepotential tocause) harmand jeopardizesafetyEvidenceBased/TherapeuticInterventionsSocial Ecology:Resources•Material•People•Socio-cultural•Health / communitySkills / Knowl /Attributes•Living skills•Self management•Interpersonal skills•Cultural competenceBeliefs/Values/Identity•Self concept /worldview•Meaning makingPhysical&SocialCapitalCultural&humancapital
  18. 18. Resilience based practice (RBP)Young people with the right mix of opportunity, motivation andresources can move beyond defensive coping into adjustment andpositive adaptation.Practitioners seek to protect and nurture a young person’s capacity tobe resilient by altering exposure to risk, influencing the experience ofrisk, averting chain reactions of negative experience and fosteringhealthy adaptation and growth.Well-timed interventions geared to respond at critical moments, havethe potential to disrupt negative cascading effects or initiate healthydevelopmental processes and positive adaptation.Masten, A. (2009) Ordinary magic: Lessons from research on resilience in human developmentUngar, J. (2011). Counseling in Challenging Contexts: Working with individuals and families across clinical andcommunity settings. California: Brooks/Cole.
  19. 19. AOD needs identification &service planning model•3 or more different drugsused in the last 4 weeks (ex.Tobacco)•Daily/Almost Daily use of atleast 1 drug in the last 4weeks (ex. Tobacco)•Meets criteria for substancedependence•Ever injected any drug•Involvement in substancerelated risk behaviours andthe experience of harmAODSeverityVulnerability/Life complexityTypicalcomplexity for ageNotusingLowHighSevereAdditionalComplexityHigh ExtremeAODSeverity Indicators
  20. 20. AOD needs identification &service planning model•Acute housing problems (last 4weeks)•Not involved in education or work(last 4 weeks)•Conflict with family or relatives (last4 weeks)•Not satisfied with physical health•Moderate or High emotionaldistress (last 4 weeks)•Current offending or involved incriminal justice system (ever)•Formal diagnosis of mental healthcondition (ever)•Attempted suicide or self harmed(ever)•Experience of abuse and neglect orchild protection involvement (ever)AODSeverityVulnerability/Life complexityTypicalcomplexity for ageNotusingLowHighSevereAdditionalComplexityHigh ExtremeComplexityIndicators
  21. 21. AOD needs identification &service planning model•Severe and high risk AODuse interrelated withcharacteristics of high toextreme vulnerability•Need interrelated AODproblems and complexityaddressed simultaneouslyby a range ofinterventionsAODSeverityVulnerability/Life complexityTypicalcomplexity for ageNotusingLowHighSevereAdditionalComplexityHigh ExtremeService required
  22. 22. AOD needs identification &service planning model•Low level or emergingAOD use combined with3 or more characteristicsof high to extremevulnerability (see above:Cohort 1)•Often younger but atserious risk of AODproblems developingand escalating•Need earlyintervention to preventtransition to cohort 1(entrenched harmfulAOD use)AODSeverityVulnerability/Life complexityTypicalcomplexity for ageNotusingLowHighSevereAdditionalComplexityHigh ExtremeServicerequired
  23. 23. AOD needs identification &service planning modelSerious AOD problemcombined with 1 or 2indicators of additionalcomplexity•Retains connection withfamily, school, employment,constructive activity• Stable living circumstances• Little or no involvement withhealth and welfare servicesNeed AOD specificintervention and earlyintervention to maintainconnectedness andparticipation (preventtransition to cohort 1)AODSeverityVulnerability/Life complexityTypicalcomplexity for ageNotusingLowHighSevereAdditionalComplexityHigh ExtremeServicerequired
  24. 24. Modalities and interventions
  25. 25. Outreach: ModalityDescription• Flexible and responsive medium for connecting with and deliveringservices to hard to reach groups. Can offer services in environmentswhere young people congregate and/or feel comfortable. Invlovescare and recovery co-ordination and timely interventions.Objectives:• Locate and connect with targeted young people• Provide therapeutic interventions according to need and readiness ofyoung people and context• Care and recovery co-ordination
  26. 26. Outreach: Interventions• Service promotion & case finding• Assertive engagement• Case work (including assessment & individualised careplanning)• Liaison & advocacy• Health education & health promotion• Foundational counselling• Behavioural & other psychosocial interventions• Family support• Home-based withdrawal• Secondary consultation to other services
  27. 27. Clinical: ModalityDescription• Sessional services are currently provided within youth AOD serviceson the basis of 1-2 hour appointments (e.g. counselling), or as briefconsultations. Suitable where life complexity and vulnerability are incheck – suitable for AOD specific counseling and family focusedinterventionsObjectives:• Offer the types of specialist interventions that are potentially bestprovided in a clinic based setting (see next slide)
  28. 28. Clinical: Interventions• AOD counselling (employing EB therapeutic models)• Pharmacotherapy• Specialist mental health care for a range of serious mentalhealth problems including: major depression, PTSD, otheranxiety disorders, bipolar disorder, psychotic illnesses• Family therapy• Grief and loss counselling• Sexual assault counselling• Medical care
  29. 29. Day program: ModalityDescription• Day Programs provide safe, stimulating and flexible environments thatyoung people can access in their own time and to the extent that theydesire.Objectives:• To offer a wide range of resources, programs and services thatmotivate, encourage and support young people to move away fromproblematic behaviours and contexts, towards more stable andhealthy lifestyle.
  30. 30. 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• Foundational counselling• Behavioural & otherpsychosocial interventions• Peer support• Supported referral andlinkages• Activity based therapeuticprogramming• Secondary consultation toother services
  31. 31. Youth Residential Withdrawal: ModalityDescription• Structured environment providing up to two weeks (or more) of safe,AOD free, age appropriate accommodation in a unit that iscontinuously staffed.Objectives:• Stabilise of client’s mental and physical health and increase accessto ongoing care• Break the escalating cycle of AOD dependence and high riskbehaviour• Build pro-social connections to support longer term behaviourchange
  32. 32. 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 otherservices)• Secondary consultation to other services
  33. 33. Residential rehabiitation: ModalityDescription• Long term residential rehabilitation geographically separate fromcommunity of origin. Provision of a holding environment - a physicallyand emotionally safe place to live and grow. Common to employ atherapeutic community modelObjectives:• To provides a safe, stable, and structured environment within whichyoung people can be assisted to secure and develop a diverse rangeof resources and assets needed for resilience and to learn to live inthe world without needing to turn to alcohol and other drugs foranswers.
  34. 34. Residential Rehabilitation: Interventions• Community as therapeutic vehicle• Primary health care and health education• Activity based therapeutic programming• Life skills programming• Motivational interviewing• Foundational counselling• Behavioural & other psychosocial interventions• Peer support• Supported referral and linkages• Secondary consultation to other services
  35. 35. Supported accommodation: ModalityDescription• Provision of structured community based accommodation in whichyoung people are provided with a range of supports while livingindependently or semi-independently.Objectives:• To provide a long term safe stable living environment and the supportrequired to develop personally and build the diverse range ofresources and assets needed for resilience and to live well withoutresorting to misuse of alcohol and other drugs.
  36. 36. Supported accommodation: Interventions• Assessment and therapeutic care planning• Medical care and Health education• Education and vocational transitions• Motivational interviewing• Foundational counselling• Behavioural & other psychosocial interventions• Family focussed interventions• Peer support• Supported referral and linkages• Secondary consultation to other services
  37. 37. Maximum security prisonWar zoneYouthservice AYouthservice BSystematisation & CompassionUnstructuredStructuredCompassionSystemisationAlienation Person Centred