Our Therapies

Protecting and promoting the health of young people

We have a dedicated Health and Wellbeing team.

Forensic Psychologist Emma Devonport
E-mail: Emma.devonport@horizonseducare.com
Phone: 01792449800

Health and Care Professions Council (HCPC): Registered Practitioner Psychologist – no: PYL28961

Domain Title: Forensic Psychologist

Job Role: Part time Consultant

Specialist field of work: Children, young people and their families, parents, carers, particularly those subject to care or mental health legislation; those involved in criminal proceedings; and those accommodated in specialist residential services.

Summary of Experience: I have been working full time in the field of psychological assessment and intervention mainly with children, young adults and their families for over 15 years. I have particular experience in working with children and young people (mainly in the 5 to 21 age range) with complex mental health, behavioural, developmental and family problems. I have experience working with young people in Residential care (Children’s Homes), Secure Accommodation (Local Authority, psychiatric and custodial ), Local Authority (Foster Care and Youth Offending services) and Child and Adolescent Mental Health Services. I have also been involved in preparing professional and expert reports in criminal and child care proceedings, undertaken private therapy work, provided supervision of psychologist and therapists from various settings and delivered training and consultation to independent child care organisations and Local authorities.

Arrangements for meeting the heath care needs of children

All medical, dental, and optician appointments are catered for within the local community unless it is possible for the child to travel to their own GP, dentist or opticians. Children requiring emergency treatment receive this via hospital local A&E department. Children at the home and the school are supported and encouraged to take responsibility for their health according to age and developmental status. Members of the care and education team use opportunities (i.e. food prep, Tec, and planning meals, PHSE) to educate children about healthy lifestyle choices. All staff support children to attend medical appointments and care staff will accompany the child as necessary. Where a child requires support regarding sexual health, guidance and direct support will be sought from local advisory services and sexual health clinics.

Drugs and other medications are prescribed under the guidance of the General practitioner and administered by an appropriate care and or education staff. Where a child requires medication to treat a diagnosed mental health problem, psychiatric guidance will be sought from the GP, local CAMHS or the CAMHS that had involvement prior to admission. Medication is administered only with the young person’s consent. Medication in both care and education settings is administered within guidance from psychiatric and or medical practitioners.

Therapies and approaches for meeting psychological, emotional and mental health

The home is registered to care for and educate children with emotional and/or behavioural difficulties (EBD). The needs of the children placed at the home (and school) vary in nature, severity, and complexity and each child presents with unique difficulties. Many of the children have additional problems such as educational and specific learning difficulties, family related problems, physical/neurological health problems, substance misuse problems or antisocial behaviour. In some instances the child will have mental health diagnosis (i.e. clinical depression, complex post traumatic stress disorder, autism spectrum disorder) and have some degree of involvement with Child and Adolescent Metal Health services (CAMHS), usually the local CAMHS and neuro developmental teams. However, some children continue to receive input from a CAMHS in another region, particularly in situations where the child has a long term involvement and/or the problems are especially complex. The staff team at the Home will make arrangements for the child to attend scheduled appointments and do its utmost to help the child comply with taking prescribed medication.Some children arrive at the home with significant problems that have not been identified or assessed. It is not uncommon for children to refuse to attend CAMHS appointments, there by preventing proper assessment and diagnosis. In these instances effort is made to engage the child in dialogue about their difficulties with a view to persuading the child to see a specialist.The home has access to a registered Consultant Forensic Psychologist who guides the staff team as necessary, and can liaise with external specialists as appropriate. It can sometimes take a period of several months to persuade a child to attend an appointment with CAMHS and to be open and honest about their difficulties. Often children will divulge personal information to specific members of the staff team, but refuse to talk to external specialists. It is important to remember that the experiences of some children have resulted in deep-seated feelings of suspicion and mistrust about the intentions of adults.Overcoming these psychological barriers can be a long slow process, requiring skill and persistence from the staff team, particularly staff at the Home. In some instances this process will reveal the presence of new problems, or provide information and insights that cast doubt on the validity of existing diagnoses. For example, a child with a diagnosis of ADHD may present with behaviours that are better understood within an attachment disorder framework. The staff team has a vital therapeutic role to play in helping children and young people who have become ‘disconnected’ to build relationships that promote social integration and feelings of belonging and acceptance.

In sum, at the point of admission each child has a unique cluster of needs, risk and difficulties. Some have need that are well understood and have support from external agencies (CAMHS, YOS, neuro development teams, educational psychologists) and professionals (psychiatry, psychology, play therapist). Other children have needs that are poorly understood and have minimal involvement from other agencies. A process is followed aimed at identifying unmet psychological needs, outlined below.

Pre admission assessment – The process of identifying care, behavioural management, educational and therapeutic priorities begins before admission. Ideally, the child is visited prior to admission by members of the staff and management team to establish rapport. Referral papers and other documents (e.g. school and mental health reports) are obtained and discussions held with the child’s social worker and other professionals. Consideration of risk-management to ensure the safety of the young person and others is fundamental to this process.

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Post admission assessment – assessment is an ongoing process which continues after admission. The aim is to gather information to develop an understanding of the child’s needs, risks and to inform the development of care, education and therapy programmes. The thrust of the assessment work is on building a positive relationship with the child to establish trust and openness with a view to gaining insight into the child’s thoughts and feelings. The assessment also draws heavily on data obtained from behavioural observation. Detailed records are kept in the child’s daily log and associated forms of record-keeping (e.g. behaviour watch, behaviour monitoring sheets). The behaviour of most children is atypical in the first few days o rweeks after admission whilst they adapt to their new living environment. Pre-existing patterns of behaviour sometimes disappear, only to emerge some time later. In addition, contact is made with the professional networks already in place to obtain further information about the child’s background and history.

Two main theoretical frameworks are used to interpret and understand the child’s behaviour, namely Attachment Theory and Social Learning Theory. These frameworks are relevant to the behaviour of all children and are particularly helpful when trying to make sense of behavioural, emotional and relationship difficulties.

Attachment Theory and Practice.

In the same way that human infants have an in-built (innate) capacity for learning to walk and talk, they also have an innate capacity for developing emotional and social attachments to other people. The primary purpose of this attachment system is to ensure the survival, safety and security of the child. The attachment process begins whilst the child is still in the womb (e.g. the foetus is able to distinguish the mother’s voice) and continues following birth, both in the new-born child and the mother, helping to cement the mother-child attachment bond. Physical closeness (i.e. touch, hugs), smells, and tone of voice, are all important in achieving a good attachment bond. After a short while the mother and baby usually develop an instinctive understanding of one another. The development of the primary attachments over the first months of life provides the foundation for subsequent patterns of attachment which, in turn, influences the establishment and maintenance of relationships with other people throughout life and contributes to the development of feelings of self-worth and self-concept. In the broadest sense, we can think of attachment relationships as “secure” or “insecure”, although in reality most people have elements of both these patterns. When a child is admitted to the home, “attachment behaviours” are activated, reflecting their attachment history. Understanding these behaviours provides insight into the psychological functioning of the child. Issues of safety and a sense of emotional security, well-being, and self-worth are often major issues for children with a history of damaged attachments, particularly those with a history of disrupted care and adverse childhood experiences such as abuse, neglect and rejection. Some children are described by mental health specialists as having an ‘attachment disorder’. Through developing an understanding of attachment patterns the staff team at the home is able to develop appropriate care and management strategies for responding to attachment-driven behavioural problems. For example, extreme sensitivity to feelings of rejection or loss (e.g. feeling rejected when a member of staff leaves the team); over-clingy dependent behaviour (e.g. excessive touching and hugging); excessive jealousy and possessiveness of other people (e.g. following a member of staff or attacking children who spend time with that member of staff); or an inability to form meaningful relationships with peers (i.e. a lack of social skills in their peer group), sometimes increasing the risk of exploitation, marginalisation and exclusion. The attachment model also provides a framework for understanding ‘therapeutic containment’ and it’s relationship with touch and physical restraint. Children who have not had ‘good enough’ early experiences of containment often have a high need for containment. Research has shown that some children in residential settings escalate their emotions and behaviour as a way of seeking physical restraint in order to gain emotional comfort from being physically touched and the sense of containment associated with this. Wherever possible the staff team at the home aims to meet the emotional and physical needs of children without recourse to physical restraint.

Social Learning Theory and Practice.

Whilst attachment theory is important in showing us that much of our emotional learning is driven by innate processes, social learning theory (SLT) is important in showing us how the world around us (i.e. the environment) influences and shapes our behaviour. In simple terms, behaviour that is reinforced is more likely to be repeated. SLT is generally associated with the American psychologist, Albert Bandura. The British psychologist, Martin Herbert, played a major role in disseminating Bandura’s ideas and research findings in the UK. Bandura undertook behavioural experiments in which he showed that children can learn to behave in very specific aggressive ways by watching adults or children behaving aggressively. Previous to Bandura many child development professionals believed that aggressive children were displaying signs of ‘deep emotional disturbance’ or were simply ‘born that way’. Bandura’s research was clear in showing that toddlers and children learn from observation and experience: they copy other people’s behaviour. Thus, a child exposed to high levels of anger and aggression in their family setting is likely to develop the same behavioural patterns. If this behavioural style becomes entrenched the child will struggle to fit into settings where this behaviour is unacceptable (e.g. school, children’s home). SLT helps us to understand that the child is not ‘bad’, but has simply learned inappropriate ways of behaving.Further, SLT helps us to think about ways to change behaviour by teaching new ways of behaving. For example, SLT shows us that behaviours that are reinforced are more likely to be repeated because they have been strengthened. Removing this source of reinforcement will help to reduce the behaviour. SLT provides a ‘model of understanding’ to explore how behaviour is learned, known as the ABC model or ‘three-term contingency’, where: A = Antecedent; B = Behaviour; C = Consequence. Thus any Behaviour (B) (e.g. eating too many chocolate biscuits) can be placed in context to determine the significant Antecedent (A) triggers (e.g. feeling tired and stressed; seeing the biscuit tin) and the immediate rewarding Consequences (C) (e.g. enjoying the taste of eating the biscuits and the sensation of feeling full). Changing the behaviour involves changing the Antecedents (e.g. managing stress in some other way; removing the biscuits from the house) and/or the Consequences (e.g. eating something else that tastes good but is less calorific). Many forms of behaviour, both simple and complex, can be analysed using the ABC model. In residential contexts it is desirable to have a ‘planned living environment’ in which antecedents that trigger difficult behavioural incidents are avoided or at least minimised. For example, if a child is observed to become upset and angry during phone contact with parents it is best to avoid phone contact around bed time. Put simply, ‘prevention is better than cure’. The SLT model also draws attention to the behaviour of staff members as ‘role models’: children copy and learn from adults.

Family Systems Theory. The home also pays heed to systemic theories. Children function within a number of different groups (e.g. family; school; friends; professionals; work; community; society). System theories recognize that behaviour is affected by each of these groups (e.g. family pressure) and that these groups influence one another through a process of feedback and communication. The systems approach is interested in how these groups interact with each other and with the individual person. The systems approach is particularly helpful when thinking about children in residential care. The House develops an awareness of the systems around each child (e.g. staff team; management team;social services; parents; relatives; commissioning teams; CAMHS; YOT; police etc) and how these systems affect one another. It is particularly important to be aware of the ‘narrative’ (i.e.the ‘story’) that builds-up around the child. Each group within the system has a story,sometimes portraying the young person in a different way (e.g. ‘good’, ‘bad’, ‘disturbed’,‘disordered’, ‘victim’, ‘naughty’, ‘ill’, ‘sad’, ‘misunderstood’).

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In some cases, one particular story dominates how the child is understood, which can be damaging if it is incorrect or biased.It is important that accurate information is exchanged between the different services, and that mistakes and misunderstandings are challenged and corrected as soon as possible. Simples trategies such as core-group planning meetings, where a key person from each agency meets at regular intervals to discuss the young person, can be very effective in managing the wider system.

Building Individual Care, Intervention and Therapy Plans.

Building Individual Care, Intervention and Therapy Plans. Care and therapy programmes are built around the needs of the young person. The primary objective is to help the child overcome obstacles and problems; to feel less distressed; and to live a more independent, productive, and socially appropriate life. The home adopts a pragmatic, flexible, approach to meeting needs because many of the children placed at the home have resisted attempts to engage them in mainstream community services (e.g. CAMHS) and formal individual work (e.g. counselling, psychotherapy). The home does not attempt to fit children into therapeutic protocols or programmes that do not suit them. The approach is similar to that enshrined in Multi-Systemic Therapy (MST)in which interventions are made in various aspects of the young person’s life (home, school, community, individual) to ensure a consistent joined-up approach that addresses relevant problems. The Registered Manager at the house holds a monthly care review meeting with the Consultant Psychologist to develop care and therapy programmes. Where possible the child’s Key Worker also attends. The Key Worker is responsible for establishing an effective working relationship with the young person and coordinating care, management, therapeutic, and education activities. The care and therapy programmes usually comprise a combination of the
following:

Behavioural supervision and behavioural management – adjusted according to individual need, for example some children require constant one-to-one supervision. Most children have unsupervised time out of the house in accordance with their care and risk management plans. Members of staff receive supervision and training in setting on maintaining appropriate behavioural boundaries; incident management; de-escalation of situations involving potential aggression; and physical intervention techniques, which are used as a last resort.

Team-based strategic approaches – for working with each child (e.g. how to manage self injurious or aggressive behaviour). The Consultant Psychologist is available to attend staff team meetings to assist in the development of strategic work, with a focus on helping staff develop a style of working that matches the needs of the child. The work is particularly informed by Attachment Theory , Social Learning Theory and Positive Psychology

Psychological supervision – is available to staff team members, particularly where a child forms a close trusting relationship and refuses to engage with external professionals.

Clinical oversight meetings between young people and the Consultant Psychologist, to review behaviour, mental health, risk and progress are available, if required

Individual psycho therapeutic and/or skills focussed work. – As noted earlier, some children continue to receive therapeutic work from external agencies (e.g. CAMHS). However, not all children agree to participate in formal individual therapeutic work. Some do not identify themselves as having emotional or psychological problems. Others recognise that they have problems, but decline to take part in formal individual therapy. Children cannot be coerced into taking part in individual therapeutic interventions, although they are encouraged to take a realistic look at their problems and the need to address their difficulties. Some children need a period of time in which they are prepared for individual work. The Prochaska-DiClemente stage model provides a useful framework for conceptualizing individual change.This model sets out several stages through which an individual must pass before committing to the process of change. Where a young person does consent to individual therapy this is sometimes provided in-house by the Consultant Psychologist or by a suitably qualified external therapist, especially where this work has commenced prior to admission. Children are often concerned about private and personal information being shared with everyone in the residential team and see individual work as way of preserving some degree of confidentiality, with the proviso that any information that has implications for the safety and welfare of others and/or the young person will need to be shared (e.g. safeguarding concerns). The home can access local CAMHS and specialist Tier 2 resources (i.e. substance misuse). Several types of individual therapy can be arranged via appropriately qualified therapists, including the following:

Individual supportive psychotherapy/counselling/ Some children benefit from long-term individual work, over a period of months or years, to provide support. The therapeutic relationship that develops can be used to establish a feeling of trust and provide a source of stability and consistency, sometimes in a context that is constantly changing (e.g. changes in the residential staff team; changes in social worker; brief contact with several external agencies, such as CAMHS, YOT etc). This individual work can be used to focus on specific problems (e.g. self-harm), whilst at other times it can be used simply as a source of support, an opportunity for the young person to talk about concerns and problems in a private setting. The term ‘supportive psychotherapy’ is used because the therapist uses a variety of strategies and techniques rather than being tied to one specific therapy model, which can be very limiting, particularly when dealing with complex problems. There may be periods when the therapy primarily involves ‘non-directive’ counselling, mainly requiring listening and reflecting, whilst at other times more focussed directive work is required (e.g. teaching skills to cope with anxiety).

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Cognitive-behaviour therapy (CBT) – The American psychiatrist Aaron Beck is usually associated with the development of cognitive therapy, which has since been used in conjunction with behaviour therapy to form CBT. CBT is now a mainstream therapy which has a strong evidence base supporting its effectiveness in overcoming many types of emotional and behavioural problems. Beck’s insight was that many patients had ‘programmed their own minds’ by repeating certain thoughts (known as ‘automatic thoughts’ or ‘self-talk’ – the things we say to ourselves). When these thoughts are unhelpful (e.g. ‘I’m stupid’; ‘I can’t do it’), and become deeply ingrained, they can lead to emotional problems (e.g. depression, anxiety, low self-esteem). Beck suggested that changing these patterns of thought (‘cognitions’) would lead to improvement in the problem: hence, ‘cognitive therapy’ was born. From the 1970’sonwards, many practitioners began to use behavioural and cognitive techniques in combination.

For example, the cognitive approach would help an anxious person to alter their style of thinking (e.g. ‘I’m no good at public speaking’), whilst the behavioural approach would help the person to conduct ‘behavioural experiments’ as a way of testing out reality and developing new skills (e.g. practising speaking in front of other people). Eventually this hybrid became known as CBT and is now recommended by NICE (The National Institute of Clinical Excellence) as the treatment of choice for many common emotional and behavioural problems(e.g. depression, anxiety, phobias).

EMDR. Eye Movement Desensitization and Re-processing is a therapy technique developed in the 1990’s by an American psychologist, Francine Shapiro13. It is used to help people overcome some forms of psychological trauma. In most instances, the effects of trauma (e.g. being in a car crash) are time-limited and resolve over a period of time without therapy. However, in some instances, due to a specific combination of the nature of the traumatic event(s) and individual personal factors, the effects of trauma are longer-lasting. In the most serious cases it can lead to a diagnosis of PTSD (Post-traumatic Stress Disorder). The condition can be very disabling (e.g. persistent flashbacks; avoidance of situations or people; disturbed sleep; nightmares; constant ‘hyper vigilance’). Shapiro stumbled on the EMDR technique by accident and developed it into a ‘therapeutic package’, now supported by training programmes and manuals. The original technique involved asking clients to make specific ‘tracking movements’ with their eyes whilst in a relaxed state and whilst visualising and thinking about the traumatic event (e.g. a car crash). The number of techniques expanded, using other ‘bi-lateral stimulation’ methods in addition to eye-tracking. It is unclear how or why the techniques work but they appear to assist with the processing of traumatic memories that are ‘stuck’ and not fully resolved. Research studies have found EMDR to be as effective as some forms of CBT in dealing with people suffering from ‘simple trauma’. In recent years NICE have approved EMDR as a technique for treating psychological trauma, including some types of PTSD.

Play Therapy Play therapy is a type of therapy that helps children to express themselves, explore their thoughts and feelings, and make sense of their life experiences. Play is a natural activity of learning, exploration and communication for children, and so the medium is considered highly ef-fective for helping children to ‘play out’ what they may find difficult to put into words. Play thera-pists will work with children of all ages in a safe and trusting environment to help shift perspectives of difficult experiences and increase self-esteem and confidence. The main aim of a play therapist is to equip children with adaptive behaviours and better coping mechanisms for everyday life. This is to help them develop a more positive view of their place in the world. Play is incredibly important for a child’s development – helping to shape key social, creative, language, emotional, cognitive and physical processes. As a result, play therapy can help children in a variety of ways, although exactly how will depend greatly on the individual needs of each child. The approach is considered particu-larly important for children who may struggle to express themselves verbally, although generally it can help children of all abilities, cultures and genders.

Approach to measuring the effectiveness & outcomes of therapeutic interventions Why measure outcomes? It is helpful to look at outcomes in any goal-driven activity. Outcome data provides information on the extent to which desired goals have been achieved, or in the process of being achieved (i.e. ‘on track’); information on ‘what works’; and whether resources can be employed more effectively to improve outcomes. The collection and analysis of outcome data also helps to focus attention on defining the nature of the goals at an organizational and individual child level. This, in turn, helps to define the nature of the enterprise so that everyone involved is clear about what it is they are aiming to achieve. External agencies (e.g. commissioning bodies) increasingly request performance and outcome data. Our primary motive for collecting outcome data is to improve the quality of our services. However, caution needs to be exercised when interpreting outcome data. Firstly, baseline data (i.e. the starting point) are often missing. There is no accepted method in children’s services for measuring the baseline (i.e. no way of measuring how complex, difficult, or challenging it is to care for a particular young person). Until such a system is developed caution needs to be exercised in comparing outcomes across organizations. Second, each child has a unique set of complex problems, thereby making it difficult to identify measures that can capture complexity and change across the population. For example, an instrument measuring depression would be relevant only to those children for whom depression is a problem. Third, measures are useful only to the extent that they provide reliable information about critical factors. For example, measuring self-esteem and demonstrating that self-esteem has improved would be of little interest if self-esteem is not relevant to the child’s difficulties. Fourthly, some measures are not sensitive to change. Consequently, repeat administration of the measure would not detect change.

Outcome targets: The home has a strong emphasis on having individualised care planning targets (i.e. individual therapeutic support and intervention plan) that attempts to identify the issues for each child in the home and a system of gathering information about the child’s journey and outcome measurements to show the progress made against the plan. The aim is to hold a meeting at admission that includes the Registered Manager of the home, education staff and consultant psychologist to share information regarding the child. The aim is to start to formulate as a team an understanding of the child needs and strengths in key areas (i.e. Behaviour, Emotional well-being, Risk to self and others, Relationships and attachments, Indicators of potential need for assessment/diagnosis). This information is used to identify targets and agree on strategies for intervention across care, education and therapy. The house manager aims to meet quarterly (ever 3 months) with education and clinical staff to review the progress the child is making in respect of the plan and if appropriate set new targets. This would also include using the evidence collected to decide if the child requires individual therapy, what form and who would be best placed to provide this.

Outcome measures: The home sometimes uses the Strengths and Difficulties Questionnaire (SDQ)to provide a global snapshot of each child. The SDQ is a widely used valid measure supported by extensive empirical data. The child version (SDQ-S) is administered to the child whilst the parent version (SDQ-P) is administered to the child’s Key-Worker. The SDQ was developed as a screening measure to identify emotional and behavioural difficulties in mainstream children. SDQs is used to detect conduct, hyperactivity, depressive and some anxiety disorders, but is poor at detecting separation anxiety or phobias Consequently, it will not capture some of the behaviours and difficulties of interest to the home (e.g. self-harm; running-away). However, the SDQ is sensitive to change in both strengths and difficulties, and is therefore repeated every three months. Additional outcome measures are sometimes used on an as-needs basis by individual therapists to asses and quantify change in relation to specific clinical problems (i.e. anxiety). For example The Becks Youth Inventory (BYI), Trauma Symptom Checklist for Children (TSCC) and Resilience Scale Questionnaire (RSQ) are sometimes used, administered and interpreted by a suitably qualified practitioner (e.g. registered psychologist).

Outcome measures: The home sometimes uses the Strengths and Difficulties Questionnaire (SDQ)to provide a global snapshot of each child. The SDQ is a widely used valid measure supported by extensive empirical data. The child version (SDQ-S) is administered to the child whilst the parent version (SDQ-P) is administered to the child’s Key-Worker. The SDQ was developed as a screening measure to identify emotional and behavioural difficulties in mainstream children. SDQs is used to detect conduct, hyperactivity, depressive and some anxiety disorders, but is poor at detecting separation anxiety or phobias Consequently, it will not capture some of the behaviours and difficulties of interest to the home (e.g. self-harm; running-away). However, the SDQ is sensitive to change in both strengths and difficulties, and is therefore repeated every three months. Additional outcome measures are sometimes used on an as-needs basis by individual therapists to asses and quantify change in relation to specific clinical problems (i.e. anxiety). For example The Becks Youth Inventory (BYI), Trauma Symptom Checklist for Children (TSCC) and Resilience Scale Questionnaire (RSQ) are sometimes used, administered and interpreted by a suitably qualified practitioner (e.g. registered psychologist).