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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]. Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for Clinicians. - PowerPoint PPT Presentation
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1
Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for
Clinicians
Jan Looman, Ph.D., C.Psych.Kingston, Ontario
2
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
3
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
4
Models of Treatment
What really is RNR? RNR vs. GLM Is the Good Lives model different?
5
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.
6
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.
7
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
8
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.
9
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
10
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
11
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
12
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)
13
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)
14
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.)
15
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
16
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
17
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
18
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.
19
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.
20
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).
21
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.
22
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)
23
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.
24
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
25
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
27
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
29
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”
30
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);
31
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.
32
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
33
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
34
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
35
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
36
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
37
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
38
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
39
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.
40
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).
41
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
42
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
43
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
44
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
45
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
46
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
47
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
48
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
49
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.
50
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
51
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
52
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
53
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
54
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
55
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
56
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
57
RTC Sex Offender Program
1. Triage Process2. What do I mean by High Risk/Needs3. RTC program
58
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
59
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
60
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
61
MAU Assessment (con’t)
1995 - developed first National Standards for sex offender treatment
established Low, Moderate and High Intensity designations
62
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
63
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.)
64
MAU
Moderate
WSBC
HISOP RTC**
**Low Pittsburgh
Low-Mod Bath
65
RTC Sexual Offender Treatment Program
66
RTCSOTP
Description of the Clientele Program Components Outcome data
67
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)
68
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
69
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
70
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)
71
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
72
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
73
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)
74
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
75
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
76
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
77
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
78
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
79
Program Structure Related to Criminogenic Needs
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
80
Program Structure Related to Criminogenic Needs
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
81
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
82
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
83
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”
84
Introductory Module
“I need to retaliate otherwise people will think they can push me around”
85
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
86
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
87
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
88
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?
89
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
90
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
91
Introductory Module- Consent Consent negotiated
Reasons for age of consent
Legal age vs. age appropriate
Consent scenarios
92
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?
93
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?
94
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
95
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
96
Autobiography and
Disclosure
97
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
98
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
99
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
100
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
101
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
102
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?
103
104
AB & Disclosure
105
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
106
AB & Disclosure
Who gets discharged? attrition table.rtf only disruptive behavior predicts discharge
107
108
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
109
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
110
Cognitive Distortions
What information has the client previously provided which is contradictory to the distortion?
What is the evidence for the thought? Remain neutral.
111
Cognitive Distortions
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.
112
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
113
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
114
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
Cognitive Distortions
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
Cognitive Distortions
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
Cognitive Distortions
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
Cognitive Distortions
Also note that there is no evidence to support the notion that cognitive distortions (as distinct from offence supportive attitudes) predict recidivism
120
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
Cognitive Distortions that Impede Empathy
Do not have victim empathy/empathy training component
Mann et al. (2011) – victim empathy not associated with recidivism
124
Cognitive Distortions
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
Social Skills Component
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
Social Skills Component
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
Social Skills Component
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
Social Skills Component
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
Individual therapy component
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
Individual therapy component
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
Community Supervision
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
Community Supervision
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
Specific Challenges with High Risk Offenders
– 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
Community Supervision
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
Specific Challenges with High Risk Offenders
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
Specific Challenges with High Risk Offenders
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
LTSO Legislation-Impact on the Community
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
LTSO Legislation-Impact on the Community
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
LTSO Legislation-Impact on the Community
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.