Clinical and service implications

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In the UK there is an increasing focus on providing specialist services for care-leavers (National Institute for Health and Clinical Excellence, 2013; National Institute for Health and Clinical Excellence & Social Care Institute for Excellence, 2010). However, very little guidance has been provided concerning what these services might look like and how they can meet the psychological needs of care-leavers. The results from this study highlight the complex psychological, emotional and social needs of young people leaving care and suggest that interventions aiming to promote secure attachments, to improve social cognition and to build skills in emotional regulation might be helpful in improving outcomes for care-leavers. In the context of the current study, assessing and working with individuals to improve emotional regulation seems of primary importance, especially given the risks associated with maladaptive coping strategies (e.g. self-harm, suicide, substance misuse;

Koenigsberg, 2010; Neumann et al., 2010). Emotional dysregulation is also a well- recognised risk factor for many psychological problems and poor outcomes

(Koenigsberg, 2010; Neumann et al., 2010; Roll et al., 2012). Taking account of these findings, dialectical behaviour therapy may be a useful intervention for young people leaving care. The primary goals of DBT focus on improving emotional regulation and reducing self-destructive behaviour (Linehan et al., 1991). There is preliminary evidence from one study that an intervention package that interweaves dialectical behaviour therapy with dyadic developmental psychotherapy is helpful in improving emotional regulation and reducing self-harm behaviour in the care-leaver population (Andrew et al., 2013).

Clinically, the finding of impaired social cognition among care-leavers is significant as deficits in interpreting the mental states of others have been shown to be an important transdiagnostic factor that increases risk to a broad range of mental health problems (Fonagy & Bateman, 2011; Liotti & Gilbert, 2011). As such, social cognition (and more broadly, mentalisation) provides an appropriate target for

intervention in young people leaving care. A range of psychological approaches could be used to improve social cognitive ability. Indeed, it has been suggested that

mentalisation is a core mechanism of change by which all effective therapies work (Allen et al., 2008; Fonagy & Bateman, 2011). One study has already demonstrated that inpatient treatment, founded upon principles of mentalisation-based therapy (Bateman & Fonagy, 1999), can bring about reductions in the tendency to over-

interpret the mental states of others (Sharp et al., 2013). Several other evidence-based interventions directly target social cognition; for example, metacognitive

interpersonal therapy (Dimaggio et al., 2007), transference focused psychotherapy (Clarkin et al., 2007) and social cognition and interaction training (Combs et al., 2007). Likewise, techniques included in other interventions provide a context that allows individuals to stand back from their immediate reactions and to think about the mental states of others. For example, interpersonal effectiveness skills training in dialectical behaviour therapy (Linehan, 1993b) and Socratic questioning in cognitive behavioural therapy (Padesky, 1993), as well as systems based approaches, such as family therapy (Carr, 2012). As well as providing an appropriate target for

interventions, it is important to bear in mind the possible impact of social cognitive deficits when working with care-leavers (and, arguably, all individuals presenting for psychological therapy). Therapists should not assume that clients have accurately understood their thoughts, emotions and intentions. Instead, they should be explicitly expressed. Likewise, a mismatch between the therapist’s own thoughts and emotions, and the inferences of their clients, might provide valuable therapeutic material within the context of a well-formed therapeutic relationship (see Andrew et al, 2013 for a description of this in practice).

The findings from the current study also underscore the importance of thinking about attachment when providing services for young people leaving care. In recent years, there has been a trend toward developing interventions based directly on attachment principles (Davila, 2003; Johnson & Whiffen, 2003), with dyadic developmental therapy perhaps the most appropriate for use with looked after children and young people leaving care (Hughes, 2004). These approaches recognise the importance of past trauma, loss and rejection, as well as the self-fulfilling nature of internal working models, and seek to target attachment-related difficulties (Levy & Orlans, 2003). It is also important to recognise that patterns of attachment are likely to be played out in relation to services. For example, those with high levels of attachment avoidance might find it difficult to trust and engage with services, whereas those with more

anxious attachment styles might become dependent on professionals. A shared

understanding of how service users relate to the service is essential in situations where transference and counter-transference issues are likely to be played out in relation to the whole team (British Psychological Society, 2007). Understanding these processes is important in reducing the risk that services respond to care-leavers in ways that replicate previous maladaptive relationship patterns (e.g. discharging individuals who find it hard to engage, or ‘rescuing’ those who become dependent on professionals). Likewise, those working with care-leavers should obtain reflective supervision to consider the impact of their own attachment style on their relationship with their clients (Smith et al., 2010). This is especially important as there is evidence that therapists with secure attachment representations are better able to respond appropriately to the emotional needs of their clients (Bernier & Dozier, 2002). Finally, it should be noted that there were a broad range of scores across the two attachment dimensions amongst care-leavers in this study, which indicates that a proportion of care-leavers in this study were ‘well adjusted’. As such, services should not assume that all former care recipients face major attachment difficulties.

The finding of high levels of attachment insecurity amongst care-leavers, in the context of research demonstrating the link between attachment and a broad range of psychological and social difficulties, suggests that early preventative strategies aiming to foster secure attachments are likely to be beneficial for those who require local authority care. Meta-analyses have shown that interventions which aim to increase caregivers’ sensitivity to an infant’s needs and signals can be useful in reducing infant attachment disorganisation (Van Ijzendoorn & Bakermans-Kranenburg, 2008).

Likewise, attachment based interventions (Lewis-Morrarty et al., 2012) and placement with securely attached adoptive parents (Dozier et al., 2001; Pace & Zavattini, 2011; Steele et al., 2008) have been shown to useful in promoting

attachment security among fostered and adopted children. Unfortunately, preventative strategies are likely to be expensive in the short term and might not yield noticeable benefits for several years. In the context of the current economic climate and political pressures, reactive individualised interventions are likely to be the predominant model for working with young people in care for the foreseeable future (Scott, 2011).

Finally, this study might have clinical implications for young adults more generally. Whilst more pronounced difficulties with attachment, emotional regulation and social cognition were observed amongst care-leavers, interaction analyses indicated that strength of the relationships between attachment anxiety, social cognition and emotional regulation did not differ when comparing care-leavers and non care- leavers. As such, those providing services for adolescents and young adults in other settings might also pay attention to the social cognitive abilities of the individuals they are working with. This is especially important as poor social cognition skills in late adolescence or early adulthood can impede educational and vocational success and friendship formation, potentially leading to isolation, anxiety and depression (Ahmed & Miller, 2011).