ACL Application in a Forensic Setting
Can we help offenders to recover from their anti-social behaviours?
Question:
I am an Occupational Therapist at Forensicare and had the pleasure of attending your Allens CDM introductory workshop. Following the workshop, myself and another OT participant, along with our wider team, discussed how we might implement the concepts within our specific setting. I have a few questions arising from these discussions:
Firstly, do you have any insights as to how someone's Level.Mode might inform whether/to what extent someone has the capacity to participate in offence-specific work? As an individual’s capacity or limitations for new learning may vary with each Level.Mode, I assume this would influence their ability to engage in this type of rehabilitative work.
Response:
Our functional cognitive abilities are critical to our ability to engage in any therapy. There are no specific Level.Mode cut-off points; generally, the model suggests that we need to look holistically and consider Can-do May-do and Will-do when we are making these decisions. There are two documents on the allencognitive website that will assist you with this decision making from a cognitive perspective.
• Analysis of Modes of Performance for the Hierarchies of Functional Cognition and Cognitive Activity Demands in the Allen Cognitive Scale Catherine A. Earhart, BA, OT Cert., OTR/L. Copyright 2017, 2023 (Revised). ACLS and LACLS Committee Analysis-of-Modes-of-Performance-4.2023-.pdf (allencognitive.com)
• Analysis of Elements of Cognitive Activity Demands for Six Cognitive Levels Analysis-of-Elements-of-Cognitive-Activity-Demands-for-Six-Cognitive-Levels-4.2023-.pdf (allencognitive.com)
Differing cognitive abilities will influence how people engage and what they can take from training/therapy. The activity analyses (links above) will help you understand the cognitive demands of activities and how they potentially link to the cognitive abilities of your client. You need to do a cognitive activity analysis of the program you are offering and that will guide you in offering it to clients. For example, you would be unlikely to include a client whose functional cognitive abilities reflect level 3 abilities in a program with a level 4 or 5 cognitive demand. However, if someone is functioning with cognitive abilities associated with Level.Mode 4.8, you may be able to adapt a level 5 program so they can participate. When the person struggles with some aspects of the Level 5 demand program, you will understand that the demand is beyond their ability, the person is not being lazy or not trying hard enough.
When I am working with young autistic people who are aggressive to people and property, I tend to be more concrete and set things out as rules if they are high 4s low 5s. “It is NEVER OK to hit/stab your brother, no matter how much he deserves it”. I start teaching theory of mind at 4.8 but I don’t expect them to develop good theory of mind till 5.4. Beginning before they are ready does have some therapeutic benefit. This is based on my clinical experience applying the ACDM theory as there is no research to back it up.
Will-do is key here. If someone comes from a childhood background where the family of origin settled disputes with their fists, lies, manipulations etc, these responses will be laid down in the brain and will be hard for someone with a cognitive impairment to change. If we think about the May-do, the person with a significant cognitive impairment is likely to always need someone to co-regulate with them, to point out the other person’s point of view and assist them to communicate, distract themselves etc.
Question:
You mentioned having prior interactions with other forensic services—I'm wondering if this discussion has previously come up in those contexts? This information would be invaluable in opening up the discussion around what should be realistically expected from our consumers during their rehabilitation journey and what supports they might need to engage in particular aspects of it. I would love to hear your perspective on this.
Response:
I agree with you and not just in forensic care. Therapists often express their frustrations with different programs, even simple things like giving helpers a list of dos and don’ts when they go on leave and wondering why people don’t follow them and seeing it as a moral issue. A forum for forensic OTs to get together would be great.