Use of DMM in “high r isk” PIMH Se r vic e Dr. Ric hard Pratt (Clinic al Psyc hologist) and Dr. Cathe rine T homas (Consultant Child Psyc hiatrist), UK
“On whic h day doe s a vic tim of r e pe ate d abuse – who should be pr ote c te d – be c ome tr ansfor me d into a pe r pe tr ator who should be punishe d?” (Pat Cr itte nde n pg. e nts, 1 st e dition, 2008) 10, Raising Par the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
Par e nt Infant Me ntal He alth Attac hme nt T e am (PIMHAT ) Wo rks in la rg e c o unty in UK with po c ke ts o f de priva tio n • Orig ina lly g o ve rnme nt funde d pro je c t no w se rvic e funde d • b y lo c a l a utho rity Aims to pro vide inte g ra te d me nta l he a lth suppo rt to • e nsure infa nts a t risk who a re a t the e dg e o f c are (0-2 ye a rs) re ma in sa fe ly with the ir pa re nts Sma ll multi-disc iplina ry te a m ta king the ra pe utic a ppro a c h • with “ha rd to re a c h” fa milie s, pa re nts c ha ra c te rise d b y de ve lo pme nta l tra uma Co lla b o ra tive wo rking with so c ia l wo rke rs a nd lo c a l • pro fe ssio na l ne two rk the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
Distinc tive Appr oac he s Outre a c h “a lo ng side fa mily” in c o mmunity - mo re “a c c e ssib le ” • Offe r the ra pe utic suppo rt to pa re nt a s we ll a s pro mo te pa re nt-infa nt re la tio nship • – c linic ia n a s “tra nsitio na l a tta c hme nt fig ure ” (I NT E GRAT I VE ) Hig h le ve l o f inte r-a g e nc y c o mmunic a tio n – sha re d risk, sa fe unc e rta inty • T a rg e ting a re a s o f hig he st so c io -e c o no mic ne e d • F le xib le – b a se d o n spe c ific ne e ds o f e a c h fa mily – va rie ty o f a ppro a c he s – a dult • psyc ho the ra py, vide o inte ra c tive g uida nc e Unde rpinne d b y Atta c hme nt T he o ry (DMM) – unde rsta nding risk a nd stra te g ie s, • c re a ting “sa fe b a se ” – pro mo ting me nta lizing Co lla b o ra tive a nd inte g ra ting o n multiple le ve ls o f c ha ng e (Co mmissio ne rs / • Ma na g e rs / L o c a l T e a ms / Co mmunitie s & fa milie s) the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
Re le vanc e and use of DMM for PIMHAT • Pro vide inte rg e ne ra tio na l stra te g ie s o f hig h risk re la tio nship • Co ntrib ute s a utho rita tive re la tio na l unde rsta nding o f risk in sa fe g ua rding c o nte xt – le ss pe jo ra tive pe rspe c tive o n pa re nta l b e ha vio r • Use o f DMM info rme d me tho ds in a sse ssme nt – CARE I nde x, Me a ning o f the Child, so me use o f AAI • He lps te a m to c o mmunic a te issue s / ne e ds to fa mily & pro fe ssio na l syste m – e spe c ia lly he lpful in hig hlig hting infant c o mpulsivity the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
Case Study S is yo ung mo the r fo re nsic histo ry / inte r pe rso na l • vio le nc e – intrusio ns o f ne g a tive a ffe c t Histo ry o f ne g le c t & a b use (physic a l) no t fully • unde rsto o d inc luding CSA b y b ro the r – fo ste r c a re fro m 13 ye a rs – inc re a sing se lf ha rm Pro misc uo us a tta c hme nts & vo la tile re la tio nship with • infa nt’ s fa the r – pre g na nt a g e d 17 PI MHAT invo lve me nt fro m pre g na nc y L a c k o f ho pe in pro fe ssio na l syste m / a c tive dislike • the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
Case Study 2 – use of DMM AAI – impo ve rishe d na rra tive / b le a k “c o nc re te ” ima g e s with limite d • a ffe c t – indic a tive o f A6 with intrusio ns o f a ng e r. Offe re d a utho rita tive re la tio na l unde rsta nding to So c ia l Wo rke r a nd o the r pro fe ssio na ls – use a s “e vide nc e ” in o rde r to c o unte r pro fe ssio na l a nxie ty (po ints o f rupture whe re re mo va l o f infa nt pro po se d) So me limite d use o f AAI na rra tive / unde rsta nding with S – “sto ry ma king • & b re a king ” (Je re my Ho lme s) Use o f CARE I nde x c o nfirme d te nta tive b o nding b ut “hig h risk” • unre spo nsive / re pe a te d to indic a te de ve lo ping sync hro no us ”c o - o pe ra tive - se nsitive ” pa tte rn a fte r 6 mo nths Pro mo tio n o f “he re a nd no w” re la tio nship thro ug h o ffe ring pre dic ta b le • a nd mo de ra te ly “e mpa thic ” re spo nse s – “c la iming ” o f this iso la te d yo ung wo ma n (Anne Alve re z) – c o nc re te e na c tme nt o f c a re (the ra pist visiting re side ntia l pla c e me nt a lo ng wa y fro m ho me / se rvic e ) the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
Case Study 3 PI MHAT the ra pist b e c o ming “tra nsitio na l a tta c hme nt fig ure ” –S • se e king he r o ut a nd a sking he r a dvic e E na b le d S to 1) inc re a se le ve l o f re g ula tio n a nd 2) inc lusio n o f • infa nt’ s inte rna l wo rld T ra uma no t dire c tly a ddre sse d b ut sta b iliza tio n tha t inc re a se d o f • fe lt “sa fe ty” le a ding to mo re a wa re ne ss o f infa nt a nd mo re a c c ura te a ppra isa ls L imite d intrusio n o f pa st tra uma in re la tio nship with b a b y a nd • a b ste ntio n fro m fo rming ro ma ntic a tta c hme nt (o ng o ing risk) Bridg e b e twe e n mo the r a nd wide r pro fe ssio na l syste m – so me • inc re a se in “e piste mic trust” the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
Se r vic e outc ome s PI MHAT ha s wo rke d with 91 fa milie s (111) pa re nts • sinc e 2015. 77% o f infa nts invo lve d with PI MHAT sinc e la unc h, • re ma in in the c a re o f the ir b irth fa milie s, a t ho me . L e ve ls o f re duc tio n in sa fe g ua rding sta tuse s ha ve • inc re a se d sinc e the pro je c t sta rte d • F ro m 2016 to 2018, sa fe g ua rding le ve l re duc e d fo r 42% o f a c c e pte d fa milie s fro m re fe rra l to disc ha rg e the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
Challe nge s of using DMM in c linic al c onte xt So me re sista nc e fo r se rvic e s to ta ke a “re la tio na l” pe rspe c tive • linke d sho rt te rm a nd pre c a rio us po sitio n o f se rvic e s Co mple xity – ho w to c o nve y to pa re nts? Ca n’ t ma ke implic it • e xplic it me re ly b y sta ting I mb a la nc e o f po we r / kno wle dg e thro ug h a sse ssme nt pro c e ss • c o uld inc re a se se nse o f impo ve rishme nt / la c k o f a g e nc y I mpo ssib le fo r c linic ia ns to b e tra ine d in a ll DMM me tho do lo g y – • e xpe nse & time fo r c o ding Ho w to use it the ra pe utic a lly (DMM is mo re e la b o ra te d a s me a ns • o f a sse ssme nt) e spe c ia lly with tra uma tize d hype rvig ila nt pa re nts Ba la nc e a utho rita tive use o f DMM with humility tha t the pa re nt is • “mo re ” a nd ha s mo re re so urc e s tha n a sse ssme nt c a n c a pture E nsuring no t misinte rpre te d / misuse d e .g . in c o urt c o nte xt • the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
Ide as for fur the r inte gr ation of DMM in e dge of c ar e se r vic e s T ra nsla ting te rmino lo g y witho ut c o mpro mising me a ning • Use o f pa re nts la ng ua g e a s de rive d fro m inte rvie w tra nsc ripts • Ho ne st b ut limite d fe e db a c k until it c a n b e re c e ive d (so me time s • re vie wing CARE I nde x c lip re tro spe c tive ly) So me time s diffe re ntia ting te a m ro le s with fa mily with re g a rd to • a sse ssme nt a nd the ra py Ba se line le ve l o f DMM kno wle dg e in te a m (inc luding se lf • a wa re ne ss) a nd wide r syste m I te ra tive use o f DMM in c a se disc ussio n / sa fe g ua rding a ppra isa l • Unde rsta nding b e tte r the inte ra c tio n b e twe e n tra uma a nd DRs • a nd ho w the se influe nc e pa re nting F urthe r de ve lo ping sug g e ste d diffe re ntia te d a ppro a c he s • re la ting to de g re e o f stra te g ic disto rtio n / psyc ho pa tho lo g y the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
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