Use of DMM in high r isk PIMH Se r vic e Dr. Ric hard Pratt - - PowerPoint PPT Presentation

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

• te 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. 10, Raising Par e nts, 1st e dition, 2008)

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

• ac 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

• 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
• 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 -

• 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
• 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

Re fe r e nc e s and c ontac t de tails

• Smith, V., Pra tt, R., T

ho ma s, C. & T a g g a rt, D. (2017) No rfo lk Pa re nt I nfa nt Me nta l He a lth Atta c hme nt Pro je c t (PI MHAP): Wo rking to wa rds inte g ra tio n in a tta c hme nt, me nta l he a lth a nd so c ia l c a re . I n T ransfo rming I nfant We llb e ing : Re se arc h, Po lic y and Prac tic e fo r the F irst 1001 Days 1001 Days e d. L e a c h, P. (L

• ndo n: Ro utle dg e )
• Mc Phe rso n, S., Andre ws, L

., T a g g a rt, D., Co x, P., Pra tt, R., Smith, V. & T ha ndi, J. (2018) E va lua ting inte g ra tive se rvic e s in e dg e -o f-c a re wo rk Jo urnal o f So c ial We lfare and F amily L aw (a c c e pte d fo r pub lic a tio n).

• Ho lme s, J. (2000) Na rra tive in Psyc hia try a nd Psyc ho the ra py: the

E vide nc e . Jo urnal o f Me dic al E thic s: Me dic al Humanitie s. 2000: 26: 92-96

• Alve re z, A. (2012) T

he T hinking He art: T hre e L e ve ls o f Psyc ho analytic T he rapy with Disturb e d Childre n (L

• ndo n: Ro utle dg e )

Co rre spo nde nc e to : ra .pra tt@ virg in.ne t

the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt

F rankfurt, 2012 Camb ridg e , 2010 Be rtino ro , 2008 Miami, 2015

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