1. No More Victims State Probation Service of Latvia Conference @ Riga 15 – 17 th March 2011 Changing Behaviour of Sex Offenders: Treatment Programmes Dawn Fisher and Elizabeth Hayes

2. Summary Importance of programmes in Criminal Justice provision What works - principles underlying effective programmes Programmes overview Interaction between custody and community treatment settings New treatment approaches

3. Sex Offenders in the Criminal Justice System Significant percentage of offenders i.e. 80,000 prisoners in English & Welsh prison system of which 6,000 are sexual offenders (13%) Registered sex offenders in 2005/6 was 58 per 100,000 of the population in England Wales Reconviction rates vary according to type of offence and level of risk deviancy i.e. RM2000: Risk category –Very high – 60% High - 40.5% Medium - 18.1% Low - 8%

4. Sexual Interests Sexual preoccupation Sexual preference for children Other offence related sexual Interests Offence Supportive Attitudes Adversarial sexual beliefs Sexual entitlement beliefs Child abuse supportive beliefs Relationships Inadequacy Distorted intimacy balance Grievance thinking Lack of emotional intimacy with adults Self ManagementLifestyle impulsiveness Poor problem solving Poor management of emotions Dynamic Risk Domains

5. Importance of treatment in Criminal Justice systems Public protection and risk management Reducing the occurrence, severity and frequency of sexual offending Rehabilitation Restorative justice

6. CJS Strategy in England & Wales Prison and probation treatment programmes from 1990s onwards Advisory panel - later became accreditation panel Influence of what works literature – 1998 – what works for probation

7. Accreditation Criteria A Clear Model of Change Selection of Offenders Targeting a Range of Dynamic Risk Factors Effective Methods Skills Oriented Sequencing Intensity and Duration Engagement and Motivation Continuity of Programmes and Services Maintaining Integrity Ongoing Evaluation

8. Underlying principles - What Works Meta analysis (Hanson2002, Losel & Schmucker 2005, 2010) Risk-Need-Responsivity Cognitive Behavioural and Social Learning Theory Skills based - generalisation and maintenance Manualised Trained and supported staff Quality assured Evaluated and monitored

9. Risk Principle – who to treat? Sexual offending treatment is prioritised for those who are at higher risk of re-offending. The higher the risk, the greater the dose of treatment. Programmes have the most impact on high risk offenders and least impact on low risk offenders.

10. Need Principle – what to treat? Treatment should focus on issues that that have been shown to raise risk of future offending. These are called Dynamic Risk Factors or Criminogenic Needs, i.e. significant causal factors.

11. Responsivity Principle – how to treat? Structured, cognitive behavioural approach with strong emphasis on collaborative enquiry and active skill-building. Motivational, conveying hope for the future. Emphasis on a constructive approach to future, rather than creating stigmatising shame about the past. Warm, empathic, reinforcing and directive therapist style. Adaptations for special needs, e.g. intellectual disabilities, personality disorders, mental health issues. Purposeful eclecticism, adapting and using methods and techniques as appropriate to the offender and his learning style. Finding the shoe that fits.

12. Treatment Methods Principally CBT plus elements of Social Learning Theory Self-analysis and cognitive restructuring Modelling of alternative thinking/behaviour Implementation of alternative thinking/behaviour Modeling of anti-criminal attitudes/behaviours Skills development

13. Factors Targeted in Treatment Programmes Cognitive support for offending Deviant sexual interests, arousal patterns, sexual preoccupation Difficulty in recognising personally relevant risk factors Difficulty in generating or enacting appropriate coping strategies Deficits in interpersonal, self-management or problem solving skills to cope with personally relevant risk factors Social support for sexual offending

14. Acquisition of Skills to Deal With: Inappropriate sexual preferences Offence supportive attitudes Overcoming intimacy deficits i.e. elevated emotional loneliness; relationship skills; insecure attachments Management of emotions Sexual preoccupation (to reduce where preoccupation sustains the offending) Maintaining change

15. Successfully delivered programmes require Skilled and enthusiastic group facilitators Good communication - case managers and programme facilitators Committed case management Effective PSR authors Good communication - workers and supervisors Quality Control and Quality Assurance issues addressed Programme providers supported Programmes monitored and evaluated Quality Control and Quality Assurance issues addressed Programmes integrated within overall Probation supervision activity

16. Therapist behaviors that enhance treatment effectiveness Empathic, genuine, warm, respectful, supportive, self disclosing Asks open ended questions, directive, flexible, encourages participation, rewarding, use of humor Attentive, confident, trustworthy, instills positive expectations, emotionally responsive

17. Therapist behaviors that reduce treatment effectiveness Aggressive confrontation, rejection, manipulation of patient, low interest, critical, sarcastic, hostile/angry Discomfort with silences, unresponsive, dishonest, judgmental, authoritarian, defensive Need to be liked, nervous, does not wait for answers, boundary problems, rigidity, coldness

18. Range of Programmes Prison – CORE 2000, Extended, Adapted, Rolling Programme, Healthy Sexual Functioning Probation – TVSOG, N-SOG, C-SOG, Internet programme All programmes currently under review

19. TVSOGP To reduce risk of re-offending by: Targeting offenders based on their risk, treatment needs and responsivity needs. Increasing offenders opportunity of leading a more fulfilling life, meeting needs by pro- social means. Statement of Purpose

20. DENIAL OFFENCE SPECIFIC PROBLEMS LEVEL OF SOCIAL ADEQUACY KNOWLEDGE OF RELAPSE Cognitive Distortions Sexual Arousal Lack of Victim Empathy Problem Solving Self Management SUCCESSFUL TREATMENT Self esteem Assertiveness Intimacy Model of Change (based on original concept by Fisher & Beech)

21. Eligibility Age = 18+ I.Q. = 80 plus Mental Health - stabilised 6 months Substance abuse stabilised Some acceptance of his conviction Recognition of need to change behaviour Willingness to participate in group-work Language requirement NB – Literacy deficits do not exclude

22. The Change Process Reduction in denial Develop/practice skills for positive lifestyle, risk management, support networks, keep safe plans Cognitive Restructuring Addressing deficits in socio-affective functioning Addressing problems of self management Better Lives Relapse Prevention Block Enhancing victim empathy Life Skills & Relapse Prevention Identify & manage difficult situations, impulsivity, links to offence triggers Life Skills, RP & skills rehearsal Problem Solving, coping, strategies, relationship skills, conflict resolution Foundation Block Taking responsibility for offending Foundation Block & throughout programme Addressing distortions Pro-offending thinking patterns Victim empathy Block

23. TVSOGP Sex offenders are heterogeneous so programme has to meet individual needs as far as possible – thus divided into blocks which can be attended/repeated as required i.e. offender requiring RP/maintenance can attend Better lives section Pre-post treatment evaluation to identify treatment needs and evaluate change

24. Programme Structure Foundation Block 10 day programme Monday – Friday 9.30am – 5.00pm x 2 weeks Total group time = 60 hours

25. MODULE CONTENTS 1 Establishing the group 1 2 Link between thoughts, feelings 2 and behaviours 3 Sexual thoughts Finkelhors Preconditions 4 Model 5 Routes to offending 6 Deciding to offend 7 Consequences of offending 8 8 Making change possible 8-9 9 Progress review and planning 10 for the future 25

26. Victim Empathy Block Twice Weekly Sessions 8 sessions X 2 hrs, Follow on from Foundation Block Total group time =16 hours

27. SESSIONS 1Introduction to Empathy 2Perspective Taking (Letter to Victim) 3 The extent of victimisation 4 The effects of sexual abuse 5Understanding the victims behaviour 6 Victim perspective role-plays 7Victims Questions 8Letter to victim (not to be sent) 27

28. Life Skills Block Twice weekly sessions 20 sessions – 2 hours duration Total group time = 40 hours

29. OUTLINE OF LIFE SKILLS BLOCK SESSIONS 1 - 2 Self Image SESSIONS 3 - 6 Positive thinking & Problem Solving SESSIONS 7 - 16 Interpersonal Skills SESSIONS 17 - 19 Problems arising in intimate relationships SESSION 20 Bringing it all together 29

30. Relapse Prevention Better Lives Block One session per week 22 sessions - 2 hours duration Total group time = 44 hours NB: if the group is larger than 8 offenders, up to 4 extra sessions will be added

31. Modules of Better lives block Familiarisation with the Better Lives Model Identifying risk factors Coping strategies Keep-safe Plan & Time Planning Guest Speaker Development of individual treatment targets Skills practice Addressing Dynamic Risk Domains Bringing it all together Develop Good Life & Keep-safe Plans Presentations to Offender Managers, who attend the last session 31

32. Substantial Emphasis on Training and Supervision (particularly important when moving to scale) Staff to demonstrate required competence prior to acceptance into training Training is assessed, staff to demonstrate required competence on training Supervision ongoing for staff skills and support and to maintain programme integrity

33. Quality Assurance Treatment Management Supervision and video monitoring To protect Programme integrity To prevent Programme drift, reversal, non-compliance To promote Treatment style

34. Quality Assurance Audit All programmes audited for compliance and clinical quality Programmes designed to have auditable products

35. Audit Criteria Compliance is the programme being managed properly is the programme being delivered as designed with the right length of treatment (dose), frequency, length of session, size of group, number of facilitators Clinical audit looks at the quality of delivery 20 factors, under 4 headings: adherence to manuals treatment style group work delivery skills responsivity

36. Evaluation and Monitoring Psychometrics Used to determine treatment needs pre- treatment Used as a measure of progress post-treatment Used to evaluate programmes

37. Evaluation and Monitoring Recidivism - reconviction data desistance frequency intensity

38. Making Changes in Programmes Role of TM – where a change needs planning outside the group session Change Control – for substantial changes Accreditation Panel guidance for the biggest changes – redesign, replacement programmes Revisions + new programmes

39. New Treatment Approaches - recent Reduced focus on denial, offence accounts and cognitive distortions Reconsideration of victim empathy Increased focus on therapist style – who works v what works Second generation programmes - increased Individualization within a standardised approach Development of strengths-based approaches i.e. GLM Enhanced focus on skills training Increased attention to contextual support, wrap-around services

40. New Treatment Approaches - future Rethinking victim empathy Low risk offenders - less treatment, more management Brain-informed, reflecting neuro-science developments Incorporate alternative techniques: mindfulness and self-compassion, non verbal therapies i.e. arts therapies (music, art, drama) Increased application of desistance theories Cross-setting versus single strand approaches

41. Low Risk Reconviction rate is < 1% over 4 years Dangers of over-treating Low risk no risk Public expectations + victims expectations Some LRSOs request treatment – ethics? Exclude LRSOs – message that some sexual crimes are not serious Risk assessment tools apply to groups not individuals How to assess 10% high risk-low risk

42. Low Risk Aims Motivation Problem Solving Resettlement Risk management – especially acute risk factors Improve cooperation with CJ and other agencies

43. Challenges for Efficient Programmes integrity and innovation Supply versus demand – access to treatment timely and sufficient Providing for diversity Staying good, getting better – continuous professional development for treatment staff and organisation Adaptation to changing environment – political and knowledge base Targets – inputs, outputs, outcomes Case management on board Meeting need managing resources – how to respond to risk and need of those not in treatment Managing expectations and aspirations

44. Custody-Community Treatment Interaction Opportunities Coherence, Continuity, Consistency Integrated or seamless treatment Through the gate provisions Programmes in institutions and community combined to enable different doses of treatment, follow-up, ongoing risk management Joint training and delivery

45. Custody-Community Treatment Interaction Challenges Same tools needed for risk & need assessment and common outcome measures Gaps and duplication in provision Differing emphases eg. - deniers, refusers - voluntary versus mandated treatment - risk management Culture, Confidence

46. Contact details elizabeth.hayes@hacic.co.uk dfisher@standrew.co.uk