assessment and treatment of high risk sexual offenders: practical guidelines for clinicians

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Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for

Clinicians

Jan Looman, Ph.D., C.Psych.Kingston, Ontario

[email protected]

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Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for

Clinicians

Note: The views expressed here are the views of the author and do not reflect the views of the Correctional Service of Canada

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Outline1. Models of Treatment - RNR vs. GLM2. Describe triage process for sex

offenders in Ontario/Canada3. What do I mean by “high

risk/needs”?4. Describe treatment process for High

Risk/Needs Sex Offenders5. Link to community treatment –

continuity of care

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Models of Treatment

What really is RNR? RNR vs. GLM Is the Good Lives model different?

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Models of Treatment RNR model is not a theory of intervention in

itself – it represents principles of effective correctional intervention (Andrews & Bonta, 2010)

derived from Andrews and Bonta’s general personality and cognitive social learning (GPCSL; Andrews & Bonta, 2010) theory of criminal behavior.

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Models of Treatment GPCSL posits that crime results when the

personal, interpersonal, and community supports for behavior are favorable to crime

Strong influences - antisocial attitudes, antisocial associates, a history of offending, antisocial personality traits.

Weaker influences - familial difficulties, poor adjustment to work and school.

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Models of Treatment RNR Principles – guide us in designing intervention within the GPCSL theory The Risk Principle - that higher levels of

intervention should be reserved for higher risk cases - low risk offenders should receive no, or very little intervention.

Risk is to be determined through validated actuarial assessment of static and dynamic risk

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Models of Treatment The Need Principle - interventions should target

criminogenic needs (dynamic risk factors). Central Eight risk/need factors (Andrews & Bonta, 2010):

– antisocial associates, – antisocial cognitions, – antisocial personality pattern, – history of antisocial behavior, – substance abuse,– family–marital, – school–work, – leisure–recreation.

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Models of Treatment Sex offender specific criminogenic needs

identified by Mann, Hanson & Thornton (2010)–Sexual preoccupation–Sexual deviance – esp. deviant arousal to

children; multiple paraphilias–Offense-supportive attitudes–Emotional congruence with children

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Models of Treatment Sex offender specific criminogenic needs

(con’t)–Lack of emotionally intimate relationships

with adults–Lifestyle impulsiveness–Poor problem solving–Resistance to rules/supervision–Hostility–Negative social influences

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Models of Treatment

Other factors identified as “Promising” criminogenic needs:– Hostility toward women– Machiavellianism– Lack of concern for others – Dysfunctional coping– Sexualized coping– Externalized coping

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Models of Treatment Non –Criminogenic Needs Hanson & Morton-Bourgon (2005) Force/violence in sex offending Neglect or abuse during childhood Sexual abuse during childhood Loneliness* Low self-esteem Lack of victim empathy Denial of sexual crime * Low motivation for treatment at intake Poor progress in treatment (post)

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Models of Treatment Within the Need Principle non-criminogenic

needs not relevant targets for intervention A caveat to this: dealing with a

noncriminogenic need may be an important strategy in the context of addressing a specific responsivity factor.

Treatment providers must build on strengths and remove barriers to effective participation enhancing responsivity (Andrews, Bonta & Wormith (2011)

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Models of Treatment The Responsivity Principle1. general - the most effective interventions

tend to be those based on cognitive, behavioral, and social learning theories

1. the relationship principle (Andrews, 1980) (establishing a warm, respectful and collaborative working alliance with the client) and,

2. the structuring principle (influence the direction of change towards the prosocial through appropriate modeling, reinforcement, problem-solving, etc.)

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Models of Treatment

The Responsivity Principle2. specific responsivity - the treatment offered

is matched not only to criminogenic need but to those attributes and circumstances of cases that render them likely to profit from that treatment

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Models of Treatment Responsivity Factors (Looman, Dickie & Abracen, 2005; Olver, Stockdale & Wormith, 2011) psychopathy Low motivation/ denial/minimization low intellectual functioning/lack of education hostile interpersonal style/disruptive Mental health difficulties personality profile

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Models of Treatment

Summary RNR Treatment directed toward higher risk clients Addresses known criminogenic needs Cognitive behavioural/social learning

approaches Emphasis on effective therapist

characteristics and role modeling delivered in a manner appropriate for the client group

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Evidence for RNR Dowden and Andrews (1999) - meta-analysis of 25

studies of treatment for female offenders effect sizes larger when criminogenic needs were

targeted. treatment services which adhered to all of the RNR

principles found to be related to the greatest reductions in recidivism, while treatment rated as inappropriate had the weakest effects.

targeting vague personal/emotional targets, family interventions not addressing criminogenic needs, and other non-criminogenic personal treatment targets were associated with no reduction in recidivism.

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Evidence for RNR Dowden and Andrews (2000) - meta-analysis 35

studies of treatments for violent offenders criminal sanctions alone no effect on recidivism any human service delivery significant positive

effect. programs which adhered to RNR principles were

more effective than those which did not Programs targeting criminogenic needs associated

with a moderate effect size - those which did not produced no significant reduction in recidivism.

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Evidence for RNR Dowden and Andrews (2000) (con’t) Programs that adhered to all three RNR principles

produced the largest effect sizes. correlation between effect size and number of

criminogenic needs targeted was .69 (p <.001) correlation between effect size and number of

non-criminogenic needs was -.30 (p <.05).

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Evidence for RNR Hanson, et al. (2009) - 23 studies of sexual

offender treatment adherence to the RNR principles greater

reductions in recidivism effect was linearly related to the number of RNR

principles adhered to. programs which adhered to none of the principles a negative treatment effect.

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Evidence for RNR Dowden, Antonowitz and Andrews (2003) - meta-

analysis of 24 studies of treatment programs which employed an RP approach in the delivery of treatment.- (7 addressed sex off).

moderate overall effect size for RP programs Coded presence of various aspects of the RP

approach (i.e., offence chain, relapse rehearsal, advanced relapse rehearsal, identification of high risk situations, training significant others, Booster sessions, coping with failure situations)

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Evidence for RNR Dowden et al (2003)

Overall, the greater the number of RP components employed in treatment, the stronger the treatment effect (r = .38, p < .01).

found that RP programs which adhered to all three RNR principles had the greatest impact, while those that adhered to none of the principles had no impact on recidivism.

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Evidence for RNRSummary

Treatment approaches which adhere to RNR principles effective in reducing recidivism for violent offending, female offenders, sexual offenders

RP approaches which adhere to RNR principles also effective

Approaches which focus on noncriminogenic needs (for SOs internalizing psychological problems denial, low victim empathy, and social skills deficits) non-effective or even harmful

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Models of Treatment Good Lives Model

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Good Lives Model Assumptions about Human

Nature Assumes all human being are practical

decision-makers and have similar aspirations and needs

one of the primary responsibilities of parents/teachers to equip people with the skills/tools to make their own way in the world

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Good Lives ModelAssumptions about Human

Nature (con’t) People formulate plans and

intentionally modify themselves and their environment in order to achieve goals

In order for people to function effectively their basic needs must be met

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Good Lives ModelAssumptions about Human

Nature (con’t) Primary human goods – have their origins in

human nature and have evolved in order to help people establish strong social networks, survive and reproduce

People derive a sense of who they are and what matters from what they do (Practical identity)

Therefore in rehab need to provide offenders with an opportunity to acquire a more adaptive practical identity

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GLM on RNRCriticize RNR approaches focus on risk reduction/management

unlikely to motivate offenders – need to have approach goals

pay attention to offender as a whole - RNR sees offender as “disembodied bearer of risk”

Lack of focus on non-criminogenic needs – therapeutic relationship

RNR approaches “one-size fits-all”

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What Does the GLM SayNine* Primary Human Goods (Ward & Marshall (2004): 1. life (including healthy living and optimal

physical functioning, sexual satisfaction); 2. knowledge; 3. excellence in play and work (including

mastery experiences); 4. excellence in agency (i.e., autonomy and

self-directedness);

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GLMNine Primary Human Goods (con’t) 5. inner peace (i.e., freedom from emotional

turmoil and stress); 6. relatedness (including intimate, romantic

and family relationships) and community; 7. spirituality (in the broad sense of finding

meaning and purpose in life); 8. happiness; and 9. creativity.

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GLM & Offending Criminogenic needs = internal or external

obstacles that frustrate and block the acquisition of primary human goods

Individual lacks the ability to obtain the good in a prosocial manner and is unable to think about his life in a reflective manner

i.e. criminogenic needs =deficiency in agency and conditions that that support agency

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GLM & Offending 4 major difficulties with offender’s life

plans that lead to offending

1. Means he uses to secure goodsa) Inappropriate strategies Violation of norms

2. Lack of scope – important good missing e.g., lack if connectedness feelings of loneliness/inadequacy

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GLM & Offending 4 major difficulties with offender’s life

plans that lead to offending (con’t)

3. Conflict among goods sought – e.g. attempt to pursue good of autonomy leads to relationship issues

4. Lack of capability – knowledge/skills deficits

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GLM & Offending Two routes to the onset of offending

1. Direct – offending is the primary focus – e.g., offender may lack the relevant competencies and understanding to obtain the good of intimacy with an adult – offending = striving for fundamental goods – intentionally seeks goods through criminal activity.

2. Indirect – pursuit of a good increases the pressure to re-offend – e.g. conflict between good of relatedness and autonomy leads to break-up of relationship loneliness/distress alcohol use offending

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GLM & Offending Offenders search for primary goods in their

environments under the guidance and constraint of their practical identity– Act in ways that they think will satisfy them– Sex offending arises because people make

faulty judgements – Lack of forethought or knowledge concerning

relevant facts

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GLM & Intervention Should be a direct relationship between

goods promotion and risk management Rehabilitation = holistic reconstruction of the

self new practical identity Focus on promotion of goods is likely to

automatically eliminate or modify risk factors Attitude of therapist – offender viewed as

someone attempting to live a meaningful, worthwhile life in the best way he can in the specific circumstances confronting him

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GLM & Intervention Tailoring of therapy to match the individual

client’s life plan and their risk factors Therapeutic task shaped to suit the person

in question Focus on approach goals rather than

avoidance of risk factors

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GLM & InterventionAssumptions/Considerations (Laws & Ward, 2011) Offenders lack many of the essential

skill/capabilities to achieve a fulfilling life Criminal behaviour = attempt to achieve

desired goods but the skills/abilities absent – alternatively:

Criminal behaviour arises from an attempt to relieve a sense of incompetence, conflict, or dissatisfaction that arises from not achieving valued human goods.

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GLM & InterventionAssumptions/Considerations (con’t) Laws & Ward (2011) The absence of certain goods more strongly

related to offending**:1. Self-efficacy/sense of agency2. Inner peace3. Personal dignity/social esteem4. Generative roles and relationships (work,

leisure)5. Social relatedness (associates).

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GLM & InterventionAssumptions/Considerations (con’t) Risk of offending reduced by assisting

individuals to develop the skills/abilities to achieve the full range of human goods

Intervention = activity that adds to an individual’s repertoire of personal functioning rather than simply removing a problem or managing a problem

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Evidence for the GLM Laws & Ward (2011) indicate (p. 202) that

the GLM has empirical support – however they fail to offer any citations

The area of positive psychology generally is empirically based however this cannot be taken as evidence that such approaches are effective with offenders

E.g. Deci & Ryan (2000) - self-determination is positively correlated with personal well-being

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Evidence for the GLMSpecific to Offenders? Case studies – which do not tell us whether or

not effective in reducing recidivism or more effective in addressing criminogenic needs

E.g. White, Ward & Collie, 2007 – Mr. C. gang member with long criminal history of violence including sexual violence– Noted that he had engaged in RNR based

interventions on previous sentences– Remained in pre-contemplation and rigid

antisocial attitudes, continued drug use

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Evidence for GLM Mr. C. (con’t) Treatment according to GLM Outcome – 14 months following release Disclosed two violent incidents “The first involved a retaliatory action after

being pushed to the ground at a party. … The second relapse occurred in response to his partner being insulted and offended. Mr. C’s reaction included “smashing” the victim and entering an emotional state synonymous with the abstinence violation effect

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Evidence for the GLMSpecific to Offenders?

Harkins, Flak, Beech & Woodhams (2012) – 76 men who participated in GLM based

community SO treatment – 701 who participated in an RP oriented

treatment

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Evidence for GLMHarkins et al.(2012) (con’t)1. pre-post treatment psychometric

assessment – measures which previous research demonstrated associated with recidivism

2. Attrition rates3. Facilitators perception of the program and

offender’s motivation4. Offender’s perception of the program

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Evidence for GLMHarkins et al.(2012) (con’t) Attrition rates did not differ significantly No difference in rates of change on

psychometric measures Facilitators liked the GLM-based module 63.7% did not think it would be appropriate

for high-risk/unmotivated clients

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Evidence for GLM Harkins et al.(2012) (con’t) Clients rating of improved understanding of

their offending - 80% of RP group compared to 46% GLM

better understanding of the positive aspects of themselves 61% for GLM compared to 20% for RP

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Evidence for GLM Harkins et al.(2012) (con’t) Rating re: changing thoughts and attitudes

in a way that they were better able to manage themselves or their reoffending 80% for RP, vs. 27% for the GLM module

thoughts and attitudes about themselves or the future were more positive - 47% for GLM vs. 20% for the RP module.

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Evidence for GLM Harkins et al.(2012) (con’t) Summary GLM module led to offenders who feel better

about themselves and their future, however did not improve their awareness of risk factors and self-management strategies

Opposite was true for RP/RNR based program

no differences overall in terms of attrition or change on risk factors

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GLM vs. RNR Does GLM say anything that RNR does

not? GLM: Criminal behaviour arises from an

attempt to relieve a sense of incompetence, conflict, or dissatisfaction that arises from not achieving valued human goods

RNR approach: crime results when the personal, interpersonal, and community supports for behavior are favorable to crime

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GLM vs. RNR

RNR focuses on the Central Eight -addressing such needs as lack of education and employment and lack of supportive, rewarding, and prosocial familial and marital relationships

GLM identifies 9 “goods” with a great deal of overlap with the Central eight

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GLM vs. RNRGLM goods

1. Knowledge2. Excellence in Play and

Work3. Autonomy

4. Inner peace

5. Relatedness/Community

6. Spirituality7. Happiness/Creativity

RNR Central Eight

1. Schooling/Employment2. Employment/leisure

3. Employment/cognitions/attitudes

4. Antisocial cognitions; antisocial personality pattern

5. Associations/Family marital

6. Antisocial attitudes7. Leisure/work/family/

associates

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GLM vs. RNR Both models discuss the importance of

acquiring skills Ward et al. claim that the GLM addresses

criminogenic needs by building strengths and being positively oriented

Andrews & Bonta(2010) discuss the importance of prosocial skills building and role-modeling by treatment providers

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GLM vs. RNR Wormith, Gendreau & Bonta (2012) - some

of the professed shortcomings of RNR and alleged differences between RNR and GLM are illusory. – E.g., the difference between addressing deficits

and building strengths. From a practical field-level perspective, the difference is mostly semantic

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GLM vs. RNR

The need to use approach goals and positive language is a contribution – field too often focused on negative

No evidence this leads to greater benefit from treatment

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RTC Sex Offender Program

1. Triage Process2. What do I mean by High Risk/Needs3. RTC program

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Triage Process in Ontario

RTCSOTP in operation from 1972 to 2011

Only institutional sex offender program in Ontario until 1989

WSBC initiated at that time 1992 Sex Offender Assessment Team

established at the Millhaven Assessment Unit

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MAU Assessment

MAU Sex Offender Assessment team assesses all sex offenders entering the Federal prison system in Ontario

In Canada sentence 2+ years served Federally Assessment addresses level of risk

(actuarial) and treatment needs

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MAU Assessment (con’t)

Initially used PCL-R, SORAG, LSI-R, RRASOR and case history

added Static-99/STABLE when available

Dropped PCL-R/SORAG in 2002

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MAU Assessment (con’t)

1995 - developed first National Standards for sex offender treatment

established Low, Moderate and High Intensity designations

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Intensity Levels With Standards we (i.e., regional sex

offender program directors) adopted these levels of intensity

RTCSOTP=high WSBC=moderate Bath (est. ~ 1992) low-moderate

late 1995 RTCSOTP focus on high risk, high treatment needs offenders

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Intensity Levels Risk/Needs defined according to

RNR principles:Risk assessed actuariallyNeed defined in terms of

established criminogenic needs (intimacy deficits, attitudes, deviant arousal, problem solving, social competence, etc.)

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MAU

Moderate

WSBC

HISOP RTC**

**Low Pittsburgh

Low-Mod Bath

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RTC Sexual Offender Treatment Program

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RTCSOTP

Description of the Clientele Program Components Outcome data

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Actuarial Risk

Instrument RTC sample (sd, n) WSBC sample (sd,n) VRAG

11.7 (10.9, 233; risk bin 6)

3.15 (8.70, 468; risk bin 5)

SRAG

18.3 (11.8, 215; risk bin 6)

7.77 (11.59, 468; risk bin 4)

PCL-R

22.8(7.8, 248)

16.50 (7.11, 442)

LSI-R

29.7 (9.1, 147)

------

RRASOR

2.23 (1.4, 276)

1.72 (1.35, 468)

Static-99/ Static-99R

5.5 (2.0, 308) / 5.3 (2.2, 308)

3.44 (2.11, 468)

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Changes over Time Static-

99R % high risk

SRAG % High risk

VRAG % high risk

LSI-R % high risk

PCL-R % high risk

RRASOR % high risk

VRS-SO % high risk

Sample 1993-1995

40.0

44.6

29.9

29.4

17.5

28.0

46.6

Sample 1998 to present

66.0

65.0

72.1

53.3

31.3

40.0

73.7

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Program Differences

Note: aHi intensity differs from Moderate bHi intensity same as moderate but different from other groups

Hi Mod Lo-Mod Lo

LSI-R b 25.1 21.9 17.3 10.3

Static-99a 5.9 4.1 2.9 1.6

STABLEa 9.5 7.0 4.8 3.5

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Diagnosis Finally, use DSM diagnoses to determine

the presence of increased responsivity needs

looked at 48 consecutive admissions to the SOTP (in 2005)

37 (77.1%) meet criteria for a personality disorder

15/37 (40.5%) have personality orders described as “severe” by the diagnostician (e.g., BPD, Narcissistic, psychopathy)

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Diagnosis (con’t)

Behaviours resulting from these PD’s lead to management difficulties in their parent institution, including long-term segregation (15, or 31%)

16/48 (31.3%) suffer from mood disorder (Depression, Bipolar Disorder)

10 (28%) suffer from psychosis

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Diagnosis (con’t) 22 (45.9%) met the criteria for a

paraphilia, most often sexual sadism or pedophilia

Nine of these 22 (41%) also meet criteria for severe personality disorder – typically psychopathy or borderline

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Deviant Arousal Every admission to our program assessed

via PPG Men with child victim audio child sexual

violence assessment (Quinsey & Chaplin, 1988)

Men with adult victims adult sexual violence assessment (Quinsey, Chaplin & Varney, 1981)

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Deviant Arousal 40% of adult rapists deviance on adult

sexual violence assessment

92% of child molesters deviant on child sexual violence assessment

24% of sample (n=657) non-responders

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RTC Sex Offender Treatment Program

Designed to be delivered over ~7 months 13-session intro module then Two primary components

1. Self Management – Disclosure; Cognitive Distortions; Emotions Management; Development of Behavioural Progression; Development of Self Management Plan

2. Social Skills – Communication Skills; Goal Setting; Problem Solving; Empathy; Assertiveness; Relationships

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RTC Sex Offender Treatment Program

4-5 group sessions per week (ideally 4) and one individual therapy session

Either alternate between Self Management and Social skills sessions (if two different delivery teams) or alternate modules

In addition milieu therapy – program staff interacting with offenders in unstructured manner on living unit

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Program Delivery Schedule

Monday Tuesday Wednesday Thursday Friday

AM

Self-

Management

B Group

PM

Self-

Management

A&B groups

Social Skills A&B

groups

Social Skills

A Group

Self-Management

A Group/Social

Skills B Group

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Program Structure Related to Criminogenic Needs

Criminogenic Need Treatment componentsAntisocial Associates/Negative

Social Influences

Social Skills/ Milieu

Antisocial cognitions/Offence

Supportive Attitudes/emotional

congruence with Children

/Resistance to Rule/Supervision

Cognitive Distortions/

Individual Therapy/Social

Skills/Milieu

Antisocial Personality Pattern

/Lifestyle Impulsiveness

Cognitive Distortions/

Emotions Management

/Individual Therapy

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Criminogenic Need Treatment componentsSubstance Abuse Emotions Management

/Individual therapy

Family/Marital problems/Lack

of emotionally intimate

relationships with adults

Social Skills / Milieu

School-work

Leisure/recreation Social Skills/

Self-Management /Milieu

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Criminogenic Need Treatment componentsSexual Preoccupation Emotions Management

/Relationships/ Individual

Therapy

Sexual Deviance Arousal Management/

Emotions management/

Individual

Poor Problem solving Problem Solving

Hostility/dysfunctional

emotions

Emotions management /

Individual therapy

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Treatment Components Wong & Hare (2005) identify as treatment

targets for psychopathic offenders

1. Dysfunctional attitudes and behaviors2. Dysfunctional emotions and lack of emotional

control3. Failure to accept responsibility for their own

actions4. Substance abuse5. Lack of work ethic, employable skills and

appropriate leisure activities6. Antisocial peers, networks and subculture

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Introductory Module Introduces offender to the program

Group rules (arrived at through group discussion)

Treatment concepts/Jargon (CBT, Offence Chain etc.)

CBT – the idea that thoughts and behavior are related new to clients– Examples to illustrate

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Introductory Module

“goof” need to fight “I need to retaliate otherwise people

will think they can push me around” “I don’t think – I just react”

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Introductory Module

“I need to retaliate otherwise people will think they can push me around”

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Introductory Module

Motivational Issues Psychopathic clients often poorly motivated

to change Motivation to change typically self-focus (get

out of prison – “good report”) Work with what you’ve got First sessions focused on motivation/goal

setting – finding reason for change

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Introductory Module

Process of change

– How we begin the change process– Cost-benefit analysis of changing– Possible selves – how do you see yourself after

you’ve completed the program– Realistic expectations for the future

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Change Process

Have offender identify a role model

“Can you name anybody from your life who is not a criminal that you might use as a role model?”

Old me /New me homework

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Old Me New Me Old Me What would you like to change about your

personality and how you act? What strengths do you have that will help you to

make these changes? New Me Based on these changes what do you think the

new me will be like? What goals do you have for yourself in this

program?

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Treatment Motivation/Goal Setting

Importance of setting goals SMART principle

– S = SPECIFIC– M= MEASURABLE– A= ACHIEVABLE– R= REALISTIC– T= TIME LIMITED

Require them to set some goals for the program and monitor progress

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Introductory Module- Consent Discussion early on in program to start

offenders thinking about issues of consent– What is consent– Conditions necessary for consent

– have to be willing to have sex– have to be able to understand possible

consequences of consenting– e.g. STDs, pregnancy

– need to be sober– Must be of age

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Introductory Module- Consent Consent negotiated

Reasons for age of consent

Legal age vs. age appropriate

Consent scenarios

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Consent Scenarios 1. You are in a bar and you are getting along well

with a woman who seems quite interested in you. However, you realize that she looks quite young -although it is certainly possible that she is 19 years old. What do you do?

2. Your 13 year old step-daughter comes into the room in a see-through night gown and cuddles up to you on the couch. No one else is home. Is she indicating that she is sexually interested in you?

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Consent Scenarios 3. You have met the same woman at the bar you

like to go to several times before. Tonight things have become very friendly and you think that she really likes you. At closing time you ask her back to your place for a drink. She accepts. What would you do from here?

4. Same situation as above except that you have been “fooling around” (i.e., kissing and caressing each other) while at the bar. At closing you ask her if she would like to “continue this at your place” - she accepts. Do you have consent? Consent for what?

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Sex and the Media Discussion of the effects of media on sexual

attitudes and behavior foster skills necessary to exercise

responsible and healthy personal choices in using media

pornography = any media that promotes unhealthy beliefs about sexuality, exploits sexuality for commercial purposes, or is sexually degrading.

degrading towards both women and men

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Sex and the Media media that is legal can be used for

unhealthy purposes. use legal pornography to prime deviant

fantasies. possible to use material that is not usually

thought of as pornography to prime deviant fantasies. E.g. TV shows, movies, commercials or magazine ads

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Autobiography and

Disclosure

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AB & Disclosure

AB outline handed out during the second intro session

Given specific deadline (i.e., first disclosure will occur…)

Meet with therapist a couple of times to discuss and track progress

Less than 10 pages too short, more than 30 too long

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AB & Disclosure includes information regarding times in their

lives where they have engaged in criminal behaviour

also periods where they have managed to remain crime free.

What was going on when things were going well vs. when things were going poorly

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AB & Disclosure

Disclosure – one session per offender 30-45 minutes presentation, break then

questions ~ 30 minutes Content of disclosure

– brief personal background – Relationship history– Offences – but no specific detail

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AB & Disclosure Questioning – by all group members Clarification Supportive challenging of

minimization/denial Not confrontational – Marshall, Marshall,

Serran & O’Brien (2011) – therapists who present as warm, empathic, rewarding and directive, but not confrontational most effective

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AB & Disclosure

Goal of these exercises/sessions to increase accountability/openness about offending/sexual deviance

NOT looking for the “truth” Official version not the true version of events

– Trauma effects recall– Reconstructive nature of memory

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AB & Disclosure

DO NOT expect offender’s account to match the official version

plausible explanation of offence that does not include victim blaming and that acknowledges impact

Is this approach effective in terms of increasing accountability?

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AB & Disclosure

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AB & Disclosure

Slight nonsignficant tendency for men discharged from treatment to deny –E.g. 36% of discharged deny facts

pretreatment compared to 26% of completers

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AB & Disclosure

Who gets discharged? attrition table.rtf only disruptive behavior predicts discharge

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B SE Wald df p Exp BStatic-99R .100 .043 6.65 1 .036 1.09

Denial of Impact – full acknowledgement

8.14 2 .017

Denial Of Impact – some acknowledgement

-.87 .307 7.99 1 .005 .420

Denial of impact – no acknowledgement

-.27 .203 1.72 1 .190 .767

Denial of sexual motivation – acknowledgment

10.84 2 .004

Denial of sexual motivation – some acknowledgement

.77 .274 7.62 1 .006 2.128

Denial of sexual motivation – no acknowledgment

.69 .292 5.564 1 .018 1.993

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Cognitive Distortions

Cognitive distortions component

Focus on becoming aware of distorted thinking

Both generally criminal and associated with sexual offending

Challenging cognitive distortions without being confrontational.

Use the group process

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What information has the client previously provided which is contradictory to the distortion?

What is the evidence for the thought? Remain neutral.

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Use of ACT model to challenge distortions

1)Awareness of distorted thinking.2)Choose to think rationally (what is true,

what is not).3)Take action - Replace with appropriate

thoughts.

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Cognitive Distortions Important notion re: cognitive distortions is

the idea of excuse making Mann & Maruna (2006; Mann & Ware, 2012)

– normal human tendency toward excuse making – excuse making is “the process of shifting

causal attributions for negative personal outcomes from sources that are relatively more central to the person’s sense of self to sources that are relatively less central” p. 156

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Cognitive Distortions ‘fundamental attribution error’ … many of

the rationalizations and minimizations offered by offenders may be situational rather than dispositional.

“When challenged about having done something wrong, all of us reasonably account for our own actions as being influenced by multiple, external and internal factors. Yet, we pathologize [offenders] for doing the same thing.” p. 158

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Cognitive Distortions No win situation: “If they make excuses for what they did,

they are deemed to be criminal types who engage in criminal thinking. If, however, they were to take full responsibility for their offences – claiming they committed some awful offence purely ‘because they wanted to’ and because that is the ‘type of person’ they are – then they are, by definition, criminal types as well.” p. 158

115


Zuckerman (1979) – people make predominantly external attributions for our failures and predominantly internal attributions for our successes.

Argue that we need to be more sophisticated in our approach to cog. Distortions

116


excuse making is a highly adaptive mechanism for coping with stress, relieving anxiety and maintaining self-esteem.

Those who assume full responsibility for their failings put themselves at risk of suffering depression.

117

Cognitive Distortions ‘revised helplessness theory’ (Abramson,

Seligman, and Teasdale,1978) individuals who have an explanatory style that invokes internal, stable and global attributions for negative life events (and external, unstable and specific attributions for positive events) will be most at risk when faced with unfortunate circumstances, such as the loss of a job or a relationship breakup.

118


Hanson & Morton-Bourgon (2004) no relationship between denial of sex crime or minimizing responsibility and recidivism

However more recent research has shown that there is a relationship between denial and recidivism for some offenders

119


Also note that there is no evidence to support the notion that cognitive distortions (as distinct from offence supportive attitudes) predict recidivism

121

B SE Wald df p Exp BStatic-99R .100 .043 6.65 1 .036 1.09

Denial of Impact – full acknowledgement

8.14 2 .017

Denial Of Impact – some acknowledgement

-.87 .307 7.99 1 .005 .420

Denial of impact – no acknowledgement

-.27 .203 1.72 1 .190 .767

Denial of sexual motivation – acknowledgment

10.84 2 .004

Denial of sexual motivation – some acknowledgement

.77 .274 7.62 1 .006 2.128

Denial of sexual motivation – no acknowledgment

.69 .292 5.564 1 .018 1.993

122

Cognitive Distortions it could be that offenders attempting to

rationalise their deviant behaviour may exhibit other low-risk characteristics and feel a need to justify their atypical behaviour, whereas offenders admitting their deviant actions may see no need to justify behaviour that is consistent with their internal representations of self.

123


Cognitive Distortions that Impede Empathy

Do not have victim empathy/empathy training component

Mann et al. (2011) – victim empathy not associated with recidivism

124


Instead discuss cognitive distortions that impede empathy

View videos to illustrate victim impact Discuss specific distortions used to

shut down empathy

125

Attitudes

Discussion of helpful vs. harmful attitudes–How do we know?

How do positive attitudes affect our behaviour?

126

Attitudes Mr. Brown was released from prison two weeks ago

and has been looking for a job. He has circled yet another ad and is on his way to another interview. He has been rejected four times even though he feels that he is well qualified to do each job. Here is an example of what he is saying to himself,

"I don't know why I'm even bothering to see the boss. I've never been able to get a good job before. I'm just a fucking failure, an ex-con. I have no money left and I won't lower myself to get welfare. I won't be able to pay the rent and I'll be kicked out of my apartment. If I don't get this job, I might as well just go back to jail. I knew I'd never make it. I might as well use the rest of my money and get drunk."

127

Attitudes "Why will he never be able to get a good job?" "What does Mr. Brown define as a failure?" "Is

getting a job the only way to define success and failure?"

"If there is no money left, are there other sources of money?"

"Why is getting welfare more problematic than going back to jail?"

"Is getting drunk a good coping strategy?" "What can it lead to?"

128

Attitudes

Identify the negative attitudes expressed which positive attitudes could be substituted How can these attitudes affect reintegration

and relapse. Identify attitudes related to areas such as

self worth, success, using support, attitudes towards change, etc. and how these relate to thoughts, feelings and behaviours

129

Emotions Management Emotions Management

Component–Addresses coping with difficult

emotional states – loneliness, jealousy, depression etc.

–Cognitive strategies – self-talk, challenging distortions

–Behavioural strategies – relaxation–Acceptance of negative emotions

130

Emotions Management Awareness of emotions – how do we

know what we are feeling?– Bodily signals– Self talk

Self monitoring homework Discussion of various “high risk” emotions

– Sadness, anxiety, anger, hostility, loneliness, shame/guilt, self pity

131

Emotions Management

Also discuss positive emotions which may place someone at risk – Distorted cognitions which accompany

feelings of happiness related to success/accomplishment

Link these emotions to behavioural progression

132

Emotions Management

Anger Discussion of role of anger

– It is a “normal” emotion– can be helpful

Cognitive and physical signals related to anger

Addressing cognitive distortions that lead to anger

133

Emotions Management

Anger Rating anger on a scale of 1-10 rather

than using emotionally based language. What does “anger 7” look like? Why is this important?

Anger funnel discussion.

134

Anger FunnelDisappointmentSadnessjealousy

LonelinessBoredom

ANGER

135

Emotions ManagementWhen Is Anger A Problem?

– When it is too frequent.– When it is too intense.– When it lasts too long.– When it leads to aggression.– When it disturbs work or relationships.– When it is unresolved.– When it hurts others.– When it is sexualized.

136

Emotions Management

Strategies for managing emotions– Assertion vs. aggression– Self-talk– Relaxation/mediation/mindfulness– Effective communication

137

Emotions Management

Sexual arousal Discussion the notion that sexual arousal is

a feeling– Can be managed like other feeling– Don’t need to act on it– Same strategies apply

Discussion of arousal management strategies

138

Arousal Management Individual therapy sessions Every offender discussion of fantasy and

how it relates to offences Sexual fantasy monitoring discussion of specific role fantasy plays in

life/offending (e.g., sex as coping) social skills training, strategies to deal with

negative emotionality (e.g., anger, depression)

139

Arousal Management Fantasy/arousal modification Covert sensitization

– develop fantasy scripts – deviant and appropriate

– Develop strategies for controlling arousal– In lab – monitor arousal while reciting script– Use strategies to diminish arousal – then use

appropriate fantasy to generate arousal– If not successful refer to psychiatrist

140

Behavioural Progression

Different ways of doing BP – e.g. Yates Kingston & Ward (2010)

Prefer simple Series of thoughts, feelings and behaviours

which culminate in sexual offence Clients to identify 7-10 such sequences If multiple offences chose “typical” offence

141

Behavioural Progression OFFENCE CHAIN EXAMPLE.docx 4 wife chain.docx approach goal.docxapproach chain.docx

142

Behavioural Progression

Also ask for distal factors related to offending– Background factors

Abuse Substance abuse Relationship problems

Present to group Constructive feedback

143

Social Skills Component

144


Majority of high risk/needs clients lack in basic social skills

Risk factors – Antisocial peers, networks and subculture– Loneliness, lack of prosocial relationships, poor

job prospects, intimacy Focusing on enhancing skills to

develop/maintain prosocial relationships Heavily focused on skill-building

145

Social Skills Component Values identification

– Serves as basis for much of discussion in coming components

– What are my values?– making decisions, solving problems and

communicating with others. – Decisions that support our values enhance our

ability to solve problems and help us live pro-social lives

146


Communication Skills – oriented toward developing appropriate relationships– Replacing aggressive communication (which

has likely been reinforcing for the client in the past) with listening skills and active listening

– Emphasis on costs and benefits of aggressive communication (decision matrix)

147


Problem solving/Assertiveness– Recognize when they are facing a problem and

develop appropriate strategies to cope (as opposed to substance abuse, violence and sex)

– Skills allow them to maintain supportive relationships and end inappropriate one

– Help them to keep jobs

148


Relationship Skills:– Emotions matter even if they are difficult to

figure out. At least need to understand that they matter to other people and be able to differentiate basic emotions.

– Dealing with jealousy– Negotiating consent– How to chose a partner– Avoiding impersonal sex

149

Relationship Skills

Disclosing criminal history to partner Role play

Privacy circle discussion Describes the development of

relationships From stranger to intimate relationships develop 3-date rule

150

Relationship Skills

151

Relationship Skills

Ideal Partner – asked to describe in terms of: Appearance, Attitudes, Education, Career, Personality traits, interests/hobbies, Religion, Cultural background, – Rank importance - 1 to 8

Is their ideal partner consistent with the values they identified earlier?

152

Relationship Skills

What do they bring to the relationship – what can they offer

Often expect more from a partner than they themselves are able to give.

Lead to discussion of re-evaluating what their expectations of a relationship are – idea of compromise

153

Relationship Skills Maintaining Relationships

– Relationships require work– Face strain from change – children, job loss– Other relationships – in-laws

Show respect Be honest and truthful Do little things to show you care Treat your partner as an equal Take equal responsibility Make time (for family, for partner, for yourself) Be open to change Maintain individuality/respect individuality of

partner

154

Relationship Skills Coping with loneliness, rejection and

jealousy Being alone vs. loneliness

– What does it mean to “be alone”– Advantages of not having a partner

Rejection – what does it mean when someone rejects you?– Possible reasons for rejection– Ways to cope

155

Relationship Skills Coping with loneliness, rejection and

jealousy Jealousy – what is jealousy and why do

we feel it– When you don't feel good about yourself– When you are dependent on your partner for

your happiness– When you don't enjoy spending time alone– When you lack social skills– When your expectations aren't being met– When you've made the wrong partner choice

156

Relationship Skills Coping with jealousy Try to determine if the jealousy is based

on fact or fear Communicate your feelings to your

partner in the very beginning Don't allow negative self-talk to get out of

hand Negotiate with your partner ways to avoid

situations that perpetuate the jealousy Seek counselling

157

Self Management Component

158

Self Management Puts everything from program together Remind themselves of goals/reasons for

change Identify risk factors and main coping

strategies Relapse Cues Appropriate use of leisure time Main sources of support Present/discuss in group

159

Individual therapy component

160


Address issues unique to the individual not addressed in group

Follow-up on issues which come up in group Assist with homework Arousal work

161


Substance Abuse– CSC has comprehensive substance abuse

programming therefore do not target directly in SOTP

– Discuss role substance abuse plans in offence progression

– Importance of avoiding substance abuse in risk management/prosocial lifestyle

– Don’t mix substance use and sex

162

Individual Therapy

Importance of rapport. Understanding that treatment with such

clients is a long term undertaking. Prepare offender for dealing with the

lapses that WILL occur Drug use Fighting Angry outbursts

163

Individual Therapy

Manipulative Behaviours– Need to keep perspective in that these can be

expected with High PCL-R clients.– Need for team communication.– Meetings with the client and all those involved

in manipulative communications. That way everyone hears the same thing

– Behavioral contracts .– What is the client really after-Is it a reasonable

request?

164

Program Referrals

RTC

WSBC

Bath SOP

Maintenance

165

Treatment OutcomeTable 4 Risk percentages for different Static-99R scores compared to published values

Static-99R

score Developmental

Sample Sexual

Recidivism

Developmental

Sample Violent

Recidivism

Observed sexual

recidivism

Observed violent

recidivism

% % %(N) 95%CI %(N) (95%CI) LT 2 4.3 7.4 0.0 (6) 20.0(10) 5.7 to 50.9

2 9.1 15.7 0.0 (10) 0 3 11.9 20.3 12.5 (16) 3.5 to 36.0 17.6 (17) 6.2 to 41.0 4 15.4 25.8 8.1 (37) 2.8to 21.3 21.6 (37) 11.4 to 37.2 5 19.6 32.1 7.4(27) 2.0 to 25.8 25.9(27) 13.2 to 44.7 6 24.7 39.2 25.7(35) 13.1to 43.6 46.2(39) 31.5 to 61.4 7 30.6 46.8 25.0(20) 9.5to 49.4 40.9(22) 23.2 to 61.3 8 37.2 54.5 25.0(20) 9.5 to 49.4 35.0(20) 18.1 to 56.7 9 44.3 62.0 30.0(10) 10.7 to 60.3 66.7(12) 39.1 to 86.2

10+ 51.6 69.0 25.0 (4) 4.5 to 69.9 25.0 (4) 4.5 to 69.9 Total

Recidivism 18.0 25.0 8.9(23) 5.4 to 12.4 31.8(63) 5.8 to 62.4

Mean score 3.15 5.4

166

Treatment Outcome Table 5 Risk percentages for different SORAG risk bins compared to published values

SORAG Risk Bin

Developmental Sample Violent

Recidivism

Harris et al.

(2003)a

Observed violent

recidivism

% % %(N) 95%CI 1 7.0 19.0 0 2 15.0 18.0 16.7(1) -13.1 to 46.5 3 23.0 29.0 10.5(2) -3.4 to 24.4 4 39.0 50.0 13.3(4) 10.9 to 25.7 5 45.0 55.0 31.7(13) 17.5 to 45.9 6 58.0 63.0 35.7(15) 21.2 to 50.2 7 58.0 63.0 33.3(11) 17.2 to 49.4 8 75.0 71.0 56.8(25) 42.2 to 71.4 9 100.0 76.0 57.1(16) 38.8 to 75.4

Total Recidivism

40.4 48.0 34.1

Total sample N

178 396 250

167

Treatment Outcome

Sexual Recidivism for men with PCL-R scores over 25 AND Static-99 over 5n=70 follow-up 4.5 years

15.7% new sexual conviction

psychometric table.docx

168

Treatment Outcome

% Sexual Recidivism

% Any Violent recidivism

RTC only (n=152) 11.8 24.3

RTC + Mod (n=24) 8.3 12.5

RTC+ Mod + Maintenance (n=11)

0 0

169

Community Treatment & Supervision

170

Community Supervision

Community treatment of high risk sexual offenders picks up where institutional treatment ends.

The aim of community treatment is not to discuss the same material as was covered in institutional treatment programs.

The goal is to apply the knowledge which offenders have gained in institutional tx. to community settings.

171


For example, institutional treatment programs typically focus on intimacy deficits as one aspect of dynamic criminogenic risk.

Institutional programs may teach the offenders some of the communication skills, skills related to dealing with jealousy, knowledge of sexuality that will increase the odds of these clients being able to establish and maintain intimate relationships.

172


However, it is not until these clients enter the community that the majority may have the opportunity to use these skills in developing a relationship.

Issues such as disclosure of offense history, overnight visits and having the partner meet with correctional staff all need to be addressed.

173

Specific Challenges with High Risk Offenders

Manipulative behaviors– Need for frequent contact with team members

involved in management of the case.– Control of living environment.– Checks with employers at worksite/via phone.– Meeting with partners of offenders.– Consequences of inappropriate behaviors

discussed.– When possible, suspension is avoided.

174


– Consequences of inappropriate behaviors discussed. Where possible these are discussed as

opportunities to learn (e.g., thinking that you can put yourself in high risk situations).

– Aggressive Behaviors: Fighting is clearly not permitted and almost

always results in suspension. Threatening and aggressive communication

is discussed in sessions and contributing factors addressed.

175


Particularly with high risk offenders, there is the need to watch for them falling into old patterns of behavior (e.g., lying about their offence history to a prospective partner, simply not informing correctional staff about the fact that they are dating someone).

We put few constraints on who sex offenders can date with exception to child molesters being involved in relationships with those who have children.

176

General Guidelines

For high risk offenders it is best that they be housed in a Community Correctional Centre (CCC) or equivalent.

These settings offer offenders with few means of support a place to live and provide enough money for basic needs.

Offenders must sleep at the CCC unless authorized in writing to stay elsewhere.

Team Supervision Unit (TSU) as another option.

177

General Guidelines

If possible, parole officers and psychology staff should be housed within the same building.

In the Toronto area all sex offenders must be assessed for treatment by staff in the psychology department.

It is assumed that, except in rare circumstances, all offenders with a recent sexual offence conviction will attend one of several sex offender specific treatment programs.

178

General Guidelines

Having psychology in the same building as CCC/TSU makes it easier for those who are only allowed limited access to the community to attend treatment.

Meetings between parole officers, psychology staff, parole supervisors occur on a regular basis.

STABLE 2007 is scored on offenders on a yearly basis/STATIC-99/99R is scored if not available on file

Individual therapy and/or group treatment are available.

179

Sex Offender MaintenanceTreatment Program-Central District

Clients attend treatment until WED. Groups begin with check in. Issues of mutual concern typically arise. Those issues related to criminogenic factors

(relationships, high risk situations) receive more attention.

Clients are asked to present a synopsis of their behavioral progressions, behavioral management plans to group.

180


The goal is to keep clients in the community and when suspension is necessary, release them at the earliest possible date.

There is a need to compromise with clients on a variety of issues.

Context becomes very important in decision making.– How has the offender been doing in the

community to this point in time.– Are we hearing about other difficulties with

client from residents at CCC.

181


Substance Abuse– Decision to suspend is client and context

dependent.– More serious drugs (e.g., opiates) typically

result in suspension whereas there is more flexibility with less serious drugs (e.g., THC based drugs).

– Issues associated with lapses/relapse addressed in detail.

182

Legal Issues and Impact on Treatment Decisions

In Canada legislation which is similar in principle to sexually violent predator legislation in the U.S. generally falls within two categories:– Dangerous Offender (DO) Legislation– Long Term Offender (LTSO) Legislation.

183

Dangerous Offender Legislation Criteria for DO designation:

– Demonstrated failure to control sexual impulses– There is a likelihood of causing injury, pain, or

other evil to other persons in the future– Because of the brutal nature of the offence.

Typically reserved for offenders with extensive criminal histories.

Must be convicted of a serious personal injury offense.

184

Dangerous Offender Legislation

Between 1977 and 1997 upon finding an offender to be a DO a judge could sentence the offender to either a determinate or indeterminate sentence.

In 1997, the law was amended and determinate sentences were removed as a sentencing option.

90% of DOs are sex offenders. 88% have a previous record of incarceration

– (2001 data used). As of 2001 there were 280 DOs in Canada.

– Fewer than 10% have been released under parole supervision.

185

LTSO Legislation-Impact on the Community

To provide an alternative to indeterminate incarceration for some sex offenders who, in the opinion of the court, while exhibiting a substantial risk, could be effectively managed in the community after a period of incarceration lasting two years or more

The court may impose a maximum of 10 years of supervision.

186


The LTSO provisions came into force on August 1, 1997.

To date, the 10-year term of supervision is most common.

An LTSO does not begin until the offender has completed serving the sentence imposed by the court and any other custodial sentence that may have been imposed.

187


LTSOs do not begin until after the Warrant Expiry Date (WED) even if the offender is in the community prior to the WED.

Some, due to “dead time” end up serving sentences of days/weeks.

As a result some of these offenders are released without any treatment having been offered/received in provincial institutions.

188


Many of these offenders impress as very high needs/high risk.

It is very difficult to suspend these offenders for any significant period of time unless there are new charges laid.

It is difficult/impossible to offer a high intensity sex offender treatment program in the community.

189

LTSO Legislation-Impact on the Community These offenders present with many

treatment needs. In the community they tend to be housed at

our CCC or supervised through the Team Supervision Unit (TSU).

Coordination with police Frequent team discussions regarding these

cases.

190

LTSO Offenders

In Ontario as of 2011 there were 178 men with LTSO– 81 were in the community.– 18 additional were suspended

Most of these are released to one of the CCCs.

191

Community Treatment Outcome

Followed 25 sex offenders released to Keele CCC in 2007

11/25 LTSO 19 were involved in treatment Of those involved in treatment, none were

suspended over an average 3.1 year follow-up.

Of the 6 who did not participate in community treatment, 3 were suspended

192

Community Treatment Outcome

None of these men were convicted of a new sexual offence in the follow-up period

Two were convicted for violent non-sexual offences

One of these received community treatment

193

LTSO Offenders

These data, which are only preliminary, suggest that even very high risk offenders can be managed effectively in the community using a team based approach.

Inpatient housing, at least at first, is typically recommended unless the individual has a prosocial and well developed support network available.

assessment and treatment of high risk sexual offenders: practical guidelines for clinicians

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