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Trauma Informed Sex Offense Specific Treatment An approach to CBT-RP Treatment Ronald J. Ricci, Ph.D.Cheryl A. Clayton, L.C.S.W.

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Presentation on theme: "Trauma Informed Sex Offense Specific Treatment An approach to CBT-RP Treatment Ronald J. Ricci, Ph.D.Cheryl A. Clayton, L.C.S.W."— Presentation transcript:

1 Trauma Informed Sex Offense Specific Treatment An approach to CBT-RP Treatment Ronald J. Ricci, Ph.D.Cheryl A. Clayton, L.C.S.W.

2 Agenda: Current state of the field Emerging theories of sexual offending (What they offer. What they dont) The knitting of these theories into an approach to treatment The missing piece The specific treatment components of the expanded model

3 Before We Start….a word about roles. The Containment Model Probation Treatment Polygraph

4 Sex Offense Specific Treatment Standard Treatment is Cognitive Behavioral Relapse Prevention (CBT-RP) Treatment Primary structure for 90+% of sexual offender treatment programs (McGrath, Cummings, & Holt, 2003). A meta-analysis of 42 treatment studies (9,454 participants) showed 12.4% recidivism for treated offenders versus 16.8% for untreated (Hanson, Gordon, Harris, Marques, Murphy, & Quinsey, et al. (2002). Recent study explored the effectiveness of intensive RP treatment on sexual re-offense. The final conclusion was that their findings generally do not support the efficacy of the RP model (Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005, p. 79).

5 … the project did not give offenders enough motivation to change and did not allow for all relevant treatment targets to be addressed. Marques, J.D., Wiederanders, M., Day, D.M., Nelson, C., & van Ommeren, A. (2005). Effects of a relapse prevention program on sexual recidivism: Final results from Californias Sex Offender Treatment and Evaluation Project (SOTEP). Sexual Abuse: A Journal of Research & Treatment, 17,

6 Reconsidering CBT-RP Treatment The treatment methods evaluated were inaugurated two decades ago Largely a one-size-fits-all model The more recent Self-Regulation Model emphasizes the etiology of sexual offending behavior including childhood sexual trauma (Ward and Siegert, 2002)

7 Some missing pieces with Standard CBT-RP Treatment Motivation (beyond fear) for clients to engage in the treatment process Therapeutic rapport with clients Safe environment in which to do emotionally difficult work Resolution of factors contributing to offending problem Considering what to approach in addition to what to avoid

8 Observations… Despite everyones best effort, sometimes there were inexplicable barriers to treatment engagement Despite apparently letter-perfect work, sometimes clients kept making the same bad choices repeatedly, or kept tripping over the same issues I just cant feel what I know I should feel I just cant do what I know I should do I hear what youre saying, and I know its right, but I just dont believe it

9 A Further Observation Clients with childhood sexual abuse (CSA) often times demonstrate lack of trust, intimacy deficits, emotional constriction, and implicit beliefs about themselves and/or their victims that impede treatment progress and contribute to re-offense risk

10 Program Philosophy Community Safety Individualized Consider client readiness Collaborative and Structured Insight oriented Based in relationship (treatment, group, inner and outer circle) Systemic

11 Procedure Ten sexual offenders in a CBT-RP treatment program with reported histories of child sexual abuse were selected to undergo EMDR trauma treatment as a adjunct to their standard CBT-RP program Pre-treatment TSI, SOTRS, and PPG measures were obtained An average of six EMDR sessions using standardized protocols (Shapiro, 2001) were conducted with the 10 EMDR-added treatment group clients. EMDR treatment was considered complete when participants reported an SUD as low as they expected their disturbance could become Post-treatment TSI, SOTRS, and PPG data were obtained for the EMDR-added treatment group. Follow up data were obtained from 8 of the 10 participants PPG data were obtained from the remaining child molesters in the same treatment program to serve as a control

12 Hypothesis Unresolved CSA inhibits full treatment engagement resulting in reduced internalization of important treatment concepts Adding trauma resolution to standard CBT-RP treatment will: Increase motivation for treatment Improve treatment engagement Increase victim empathy Facilitate internalization of treatment concepts

13 Results All six subscales of the Sex Offender Treatment Rating Scale (SOTRS) showed significant pre-post EMDR improvement Insight, Sexual Thoughts, Risk Awareness, Motivation, Empathy, Disclosure

14 Other Findings Reduction in deviant sexual arousal to age and gender of victim(s) of conviction as measured by Phallometry These reductions were maintained at 6 and 12 month month follow-up

15 Phallometry Results

16 Qualitative Results Recognition of Contributors to Distorted Beliefs I think what he done to me made me think its okay to have sex with younger people as long as you dont force them. As long as they say okay. Increased Participation in Group changed how I feel about myself and kind of raising my head up and that I am a good person and do have good things to offer in group, and to other people too. Increased Empathy I can, I can feel the hurt of my own victimization, as well as my victim. Clarification of Thoughts It used to be like, like my mind was like a plate of spaghetti. Id look at it, and it was all mixed up, twisted. Now my mind, its like theres meat here, and potatoes, and a vegetable over here. Its like that now.

17 Implications Trauma informed Sex Offense Specific Treatment provides the potential for addressing implicit beliefs and deviant arousal contributing to sexual re-offense risk Potential for sustained reduction in deviant sexual arousal responses which has proved difficult to achieve with current treatments Provides potential to enhance CBT-RP treatment given recent evidence of the limited effectiveness of current treatments for sexual offenders

18 What does a trauma informed approach to therapy add to the treatment process? Motivation Therapeutic rapport Safe environment in which to do emotionally difficult work Resolution of factors contributing to offending problem Considering what to approach in addition to what to avoid

19 Basic Treatment Structure (expanded treatment model) Sex offense specific Risk & Needs Assessment Objective measures (Polygraph, Penile Plethysmograph) Weekly facilitated peer process group with CBT-RP treatment including affect tolerance and skills training Individualized trauma treatment at relevant points Support involvement with focus on accountability, communication, and relationship Collaborative approach (Probation, treatment, client, support system, polygraph)

20 Treatment Theories The overarching program model and the specific treatment components consider: Trans-theoretical Change Model; Risk, Needs, Responsivity Model, Self- Regulation Model, Good Lives Model, and Foundational Issues/Trauma Model

21 Prochaska and DiClementes Stages of Change Model Stage of ChangeCharacteristicsTechniques Pre-contemplation Not currently considering change: "Ignorance is bliss" Validate lack of readiness Clarify: decision is theirs Encourage re-evaluation of current behavior Encourage self-exploration, not action Explain and personalize the risk Contemplation Ambivalent about change: "Sitting on the fence" Not considering change within the next month Validate lack of readiness Clarify: decision is theirs Encourage evaluation of pros and cons of behavior change Identify and promote new, positive outcome expectations Preparation Some experience with change and are trying to change: "Testing the waters" Planning to act within 1month Identify and assist in problem solving re: obstacles Help patient identify social support Verify that patient has underlying skills for behavior change Encourage small initial steps Action Practicing new behavior for 3-6 months Focus on restructuring cues and social support Bolster self-efficacy for dealing with obstacles Combat feelings of loss and reiterate long- term benefits Maintenance Continued commitment to sustaining new behavior Post-6 months to 5 years Plan for follow-up support Reinforce internal rewards Discuss coping with relapse Lapse Resumption of old behaviors: "Fall from grace" Evaluate trigger for relapse Reassess motivation and barriers Plan stronger coping strategies

22 Risk Need Responsivity Approach Andrews & Bonta, 1998 Risk Principle – concerned with matching risk level to treatment dose Need Principle – states treatment should target criminogenic needs Responsivity Principle – concerned with ability to reach and make sense to treatment recipient

23 Risk Need Responsivity : What It Does Reduce maladaptive behaviors Eliminate distorted beliefs Remove problematic desires Modify offense-supportive emotions and attitudes

24 Risk – Need: What It Doesnt Consider contextual factors Consider the relationship between risk factors and human needs or goods Address treatment readiness Focus on therapeutic relationship, therapist factors, offender attitudes

25 Self-Regulation Model of the Relapse Process Ward, T., Hudson, S.M., & Keenan, T. (1998)

26 SRM in brief… Contains a number of pathways, representing different combinations of offense-related goals and distinct regulation styles in relation to sexually offense contact. (Ward et al., 2004)

27 Empirical Support for SRM Bickley, J.A. & Beech, R. (2002). An empirical investigation of the Ward & Hudson self- regulation model of the sexual offense process with child abusers. Journal of Interpersonal Violence, 17, Bickley, J.A. & Beech, R. (2003). Implications for treatment of sexual offenders of the Ward and Hudson model of relapse. Sexual Abuse: A Journal of Research and Treatment 15(2), Ward, T., Bickley, J., Webster, S.D., Fisher, D., Beech, A., & Eldridge, H.(2004). The Self- regulation Model of the Offense and Relapse Process: A Manual: Volume I: Assessment. Victoria, BC: Pacific Psychological Assessment Corporation. Webster, S.D. (2005). Pathways to sexual offense recidivism following treatment: An examination of the Ward and Hudson self-regulation model of relapse. Journal of Interpersonal Violence, 20, Yates, P.M., & Kingston, D (in press 2006). Pathways to Sexual Offending: Relationship to Static and Dynamic Risk Among Treated Sexual Offenders, Submitted to Sexual Abuse: A Journal of Research and Treatment. Yates, P.M., Kingston, D., & Hall, K. (2003) Pathways to Sexual Offending: Validity of Hudson and Wards (1998) Self-Regulation Model and Relationship to Static and Dynamic Risk Among Treated High Risk Sexual Offenders. Presented at the 22 nd Annual Research and Treatment Conference of the Association for the Treatment of Sexual Abusers (ATSA). St. Louis, Missouri: October 2003.

28 Vulnerability Factors Ward & Siegert 2002 Intimacy & Social Skills Deficits Distorted Sexual Scripts Emotional Dysregulation Offense Supportive Beliefs Any or all of the above PLUS Deviant Sexual Scripts (oftentimes from childhood sexual victimization)

29 SRM – Offense Related Goals Avoidant Approach

30 SRM – Regulation Styles Under-regulation Mis-regulation Effective regulation

31 SRM – The Four Pathways Avoidant – Passive Avoidant – Active Approach – Automatic Approach – Explicit

32 Summary of Four Pathways PATHWAY SELF- REGULATORY STYLE DESCRIPTION Avoidant- Passive Under- regulation Desire to avoid offending but lacks coping skills to keep it from happening- escape from self-awareness Avoidant- Active Mis-regulation Desire to avoid offending but uses ineffective or counterproductive strategies Approach- Automatic Under- regulation Overlearned sexual scripts, impulsive, poorly planned behavior. (Auto-pilot) Approach- Explicit Effective regulation Desire to sexually offend with effective strategies towards that end

33 Treatment Targets for Avoidant-Passive Discover goals and vulnerability factors Improve coping (self- regulation) skills Develop goods-seeking strategies Raise awareness of offense process (where was avoidance goal abandoned) Cognitive distortions Social skills Problem-solving skills Meta-Cognition skills

34 Treatment Targets for Avoidant-Active Discover goals and vulnerability factors Alter coping skills Decision-making skills Raise awareness of offense process (where was avoidance goal derailed) Emotion regulation Cognitive distortions

35 Treatment Targets For Approach-Automatic Alter the over-learned cognitive & behavioral scripts Resolve foundational issues Alter offense-related goals Victim impact Recondition deviant arousal Emotion regulation

36 Treatment Targets for Approach-Explicit Examine core schema including view of self, intimacy, and sexuality Create atmosphere conducive to disclosure Alter route to securing human goods Cognitive restructuring External monitoring, supervision, support

37 SRM: What it Does… Considers etiology that then guides treatment intervention Considers differences in offense styles that then guides treatment goals

38 SRM: What It Doesnt… Provide a means of addressing vulnerability factors beyond self- awareness Consider the contextual variables of the therapy

39 The Good Lives Model of Offender Rehabilitation Ward, T., & Gannon, T. (2006) Ward, T. & Stewart, C.A. (2003)

40 GLM Says… Human beings (of which SOs are) are goal directed organisms predisposed to seek a number of primary goods.

41 GLM believes…. The individual commits criminal offenses because he lacks the opportunities or skills to obtain valued outcomes in socially acceptable ways.

42 Primary Goods Include… Life (healthy living & functioning) Pleasure Knowledge Excellence in play & work Agency, autonomy, self-directedness Inner peace Friendship, relationship, intimacy Community Spirituality Happiness Creativity

43 GLM assumes… Core values drive daily activities and lifestyle. Daily activities and lifestyle shape self- perception.

44 GLM Recommends Obtaining a holistic and broad understanding of offenders lifestyle leading up to the offending, and using this knowledge to help him develop a more viable and explicit good lives plan.

45 GLM says Human beings are contextually dependent organisms. Rehabilitation must consider the match between the offenders characteristics and the environment into which he lives/will live.

46 In the GLM CRIMINOGENIC NEEDS are internal or external obstacles that frustrate and block the acquisition of primary human goods.

47 FOUR Problems that Manifest in Criminogenic Needs or Dynamic Risk Factors Means – used to secure goods may be inappropriate strategies Scope – of goods the offender considers or has access to may be inadequate Conflict – between goods. For example, use of domination to gain autonomy thwarts the good of intimacy Capability – lack of skills or knowledge

48 GLM- Both/And, not Either/Or Managing risk without concern for goods promotion or well-being could lead to a disengaged and hostile client Simply seeking to increase the well- being of an offender, without regard for his level of risk, may result in a happy but dangerous individual

49 GLM: What it Does… Addresses treatment motivation Frames offending in non-threatening and accessible context Offers replacement behaviors

50 GLM: What It Doesnt… Resolve foundational issues that hamper the ability to develop skills necessary to attain human goods Resolve the developmental issues that contribute to the offense pathways

51 The Missing Piece A Trauma Informed Lens Through Which To View The Problem

52 This is not your fathers trauma We came to recognize that other trauma related issues often surface and are resolved in the process of trauma treatment. The etiology of the offending problem often involves issues other than sexual abuse. Other issues interfering with the ability to form intimate peer relationships (e.g., loss, rejection, attachment ruptures, physical and emotional abuse) came to light as relevant in the trauma processing. These are what we recognize as dynamic risk factors. Understanding and resolving the origins increases the chances of improved treatment engagement AND sustained treatment effects.

53 Trauma Informed Lens Adaptive Information Processing F. Shapiro The approach is to view clients through the lens of looking for etiological issues at the beginning and throughout the treatment process and recognize that dysfunctionally stored memories from childhood/adolescence set the stage for future behavior and can push problematic behavior in adulthood. We look for the implicit beliefs that stem from childhood events including beliefs about the world in general as well as views of self and others that contribute to dynamic risk factors. These issues can potentially be resolved as we assist clients in clarifying them. As a by-product, clients often come to recognize a connection to their sexual offending which furthers their motivation to address them throughout the treatment process. It has much to do with the way we view our clients problem.

54 Stages of Treatment

55 Why Am I Sitting Here? Pre-contemplation stage of change Offense introduction Do NOT coach or you will create a Parrot Tag subtle distortions, minimizations, etc. aloud and predict clarity in future

56 Pacing & Leading Attacking a clients position, particularly prior to establishing a working therapeutic relationship, is likely to damage sense of self, impede trust-building, and entrench the clients negative position. Aggressive treatment approaches markedly decrease the chances that the sexual offender will attain treatment goals. (W.L. Marshal et al. 2002)

57 Pacing & Leading (cont) Having the offender "parrot" a list of risk avoidant techniques (that internally he believes has nothing to do with him) results in a client that looks and sounds safe, but that will likely choose not to be safe when out from under the watchful eye of containment. Attempts to reduce deviant arousal prematurely, while cognitive distortions remain (part of her really did like it; he's doing fine, it didn't really affect him as they say), is destined for failure.

58 Pacing & Leading (contd) The pacing of treatment is important. For example, Ward, Yates & Long (2006, p. 76) caution that self efficacy should not be enhanced until offense-avoidance skills are effectively developed and have become part of the individuals repertoire and regular functioning. This is because an increase in efficacy expectations without the development of concomitant skills can place the individual at higher risk to re-offend.

59 What Is This Problem Called Sexual Offending? Pre-Contemplative or Contemplative Stage of Change Non-threatening education about the problem Personalize concepts as ready Do not create an us-them dynamic Importance of Pacing & Leading

60 Psycho-Education Topics Woven in to Process Group (as needed) Health Communication Assertiveness Training Anger/Behavior Management Stress Management Cognitive Restructuring Healthy Sexuality Empathic Interaction Sexual Reconditioning Relapse Prevention

61 How Does The Problem Relate to Me? Moving from Contemplation to Preparation and Action Stages of Change Message: The group wants to collaborate with the client to help him figure out his problem

62 Full Offense History Disclosure Polygraph Expectation from beginning is that full disclosure is important Preparation is done with group support Less than perfect offense introduction is tolerated, flagged aloud for future intervention Not everyone will be here at this point

63 Life History-Sexual Development What clients are encouraged to look at here are dependent upon their identified offending pathway Allows for the establishing therapeutic rapport Allows for connection between clients Identification of vulnerability factors and trauma targets

64 Life / Sexual Development History – Avoidant Passive Pathway Avoidant-Passive offenders are encouraged to look at life history with an eye towards understanding key experiences and events that impact present level of functioning. Naturally, the clients life choices and current behaviors are selections he makes based on his core beliefs, shaped through the lens of his view of the world. These, then, can be examined in relation to the human goods he was seeking through his offense-related behaviors. For example, early experiences may have left him vulnerable to feelings of abandonment, and ill-equipped to manage those feelings when they arise. This may create a core belief that he is unworthy of relationships which, coupled with his innate need for intimacy, may lead him to seek intimacy with someone who is non-judgmental, less-threatening, and easier to impress, such as a child.

65 Life / Sexual Development History – Avoidant Active Pathway Avoidant-Active offenders are encouraged to look for life experiences that make them vulnerable to offending. There is a relationship between life events, dynamic risk factors, and the clients search to achieve primary human goods. The client is looking back, therefore, for life events that shaped his core beliefs in such a way that his efforts to obtain human goods took the form of offense- related behaviors. They may also discover origins of adherence to ineffective strategies that result in goal failure (i.e., avoiding offense-related behaviors).

66 Life / Sexual Development History – Approach Automatic Pathway Approach-Automatic offenders are looking for life experiences that fostered and entrenched long-standing scripts from which they automatically respond to situational cues. Some cognitive scripts evident in these types of offenders include a sense of entitlement (including sexual entitlement), hostile attitudes, stereotyped beliefs, suspiciousness, and distorted beliefs about children/females, child development, etc.

67 Life / Sexual Development History – Approach Explicit Pathway Approach-Explicit offenders are looking for origins of well-entrenched offense- supportive attitudes. He may also be able to discover origins of entitlement, or desires for retribution. As he identifies the meaning of these early experiences to his offending, he also comes to see that he was attempting to achieve life goals/human goods, and is more open to looking at other, pro-social ways he might be able to achieve those goods/needs.

68 Trauma Treatment Trauma Treatment is done at this point to target those memories identified as contributing to development of offending problem (attachment issues, intimacy deficits, physical, emotional, sexual abuse). Those issues consistent with the Self-Regulation Model etiological pathways.

69 Final Form of Offense Introduction A complete and distortion-free offense introduction Respectful language Do not include legal consequences Collaboratively identify offense pathway and tailor treatment plan accordingly Non-deceptive full disclosure polygraph

70 Sexual Offense Histories Include all novel pathways Refine pathway analysis Extract distortions, rationalizations, etc. (the grease that moves the wheel) Lays groundwork for offense pattern

71 The Problem Tends to be Cyclical Clarify awareness of risk of future offending If I reengage in problematic behaviors identified in treatment my risk to sexually re-offend is increasing

72 Sexual Reconditioning For those with documented deviant arousal only Do not attempt until all evidence of cognitive distortions eliminated

73 What Is The Cyclical Nature of MY Problem? Vulnerability Factors Triggers, Stressors, Motivators Maladaptive Coping Skills Selections, Planning, Grooming, etc. Post-Offense Evaluation

74 Trauma Treatment Trauma Treatment done here on those issues that clients and clinicians note client continues to trip over. These are typically the issues triggering the beginnings of offense pattern (feelings of abandonment, overwhelming need to please others, feeling used, etc.)

75 How Can I Avoid Doing This Again? Predicted pattern of offending Contributing, Vulnerability, and Risk factors Personal Values, Human Goods, Primary Goods, Needs

76 Contextual – Systemic Approach Community support person(s) as treatment partner Human beings are interactive and live in context Plans must realistically match environment

77 Relapse Prevention-Good Life Internal Triggers & Responses External Triggers & Responses Achievement of Human Goods Typically a recounting of the life they have been living as treatment has progressed

78 Practice

79 Phase-Out If probation supervision remaining after treatment completion, client develops a plan to phase out of weekly treatment attendance.

80 What does a trauma informed approach to therapy add to the treatment process?

81 Related Publications Ricci, R.J., & Clayton, C.A. (in press May 2009). EMDR with sex offenders in treatment. In R. Shapiro (Ed.) EMDR Solutions II for depression, eating, performance, and more. Norton. Ricci, R. J., & Clayton, C.A. (2008). Trauma resolution treatment as an adjunct to standard treatment for child molesters. Journal of EMDR Practice and Research, 2(1); Ricci, R. J., Clayton, C.A., & Shapiro, F. (2006). Some effects of EMDR on previously abused child molesters: Theoretical reviews and preliminary findings. The Journal of Forensic Psychiatry & Psychology, 17(4); Ricci, R.J. (2006) Trauma resolution using EMDR with an incestuous sex offender: An instrumental case study. Clinical Case Studies, 5(3),

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