2. The Counseling and Psychotherapy Centers The Counseling and Psychotherapy Centers Key Principles for Therapeutic Interventions Website: cpcamerica.com Presenters: Barry Anechiarico Timothy Sinn The R.U.L.E. Program

3. The Counseling and Psychotherapy Centers The Counseling and Psychotherapy Centers Part I Interpersonal Neurobiology Putting it all together Presenters: Barry Anechiarico The R.U.L.E. Program

4. 1.What does the research tell us about the Risk Factors? 2.What psychological models can we use to organize these factors so they reflect what we know about the mind? 3.What treatment models can we use to develop interventions?

5. Criminogenic needs are not treatment interventions RNR is not a clinical intervention or psychological theory. Criminogenic factors need to be translated into psychological traits that are understood in psychological theory Clinical interventions are designed to address psychological traits The RULE treatment curriculum is built on established clinical theory, practice methods and interventions designed to impact criminogenic needs.

6. Taking sexual pleasure from someone against their will. Taking sexual pleasure from someone against their will. WHAT: the Disorder. Behavior Disorder and a Character Disorder Psychological- an extortion of intimacy Neurological- Limbic dysregulation and low-mode processing (Brain-based intervention) HOW: the of behavior. HOW: the Mechanism of behavior. Stimulus/response: (Triggers, cycles, low response flexibility) WHY: the of the behavior. WHY: the Motivation of the behavior. Maslow (wants/needs) Approach/Avoidance strategies Drives: fight, flight, feed, fornicate How do we understand sexual deviance?

8. Stable variables: 1.Significant Social Influences 2.Intimacy Deficits: 1: Intimate Partners 2: Emotional Identification with Children 3: Hostility toward women 4: General Social Rejection/Loneliness 5: Lack of concern for others 3.Sexual Self-Regulation 1: Sexual Pre-occupation/sex drive 1: Sexual Pre-occupation/sex drive 2: Sex as Coping 2: Sex as Coping 3: Deviant Sexual Interests 3: Deviant Sexual Interests 4. Attitudes Supportive of Sexual Assault 4. Attitudes Supportive of Sexual Assault 1: Entitlement 1: Entitlement 2: Rape Attitudes 2: Rape Attitudes 3: Child Molester Attitudes 3: Child Molester Attitudes 5. Cooperation with Supervision 6. General Self-Regulation 1: Impulsive Acts 1: Impulsive Acts 2: Poor Cognitive Problem Solving 2: Poor Cognitive Problem Solving 3: Negative Emotionality/Hostility 3: Negative Emotionality/Hostility

9. The psychology of sexual deviancy Attachment/Intimacy deficits (Core dynamic risk factor) Narcissism (Exploitative relational style used to self-regulate) Self-esteem dysregulation (Emotional instability/vulnerability to shame) Sexual and aggressive behavior (Break down product of attachment deficit)

10.   Supportive social network   Secure pair bonds   Avoid high risk situations   Manage stress by means other than sexual fantasies [4/99[Sex Abuse.., Knowing What Works, Hanson.] A Low Risk Offender

11. Interpersonal Neurobiology: Trauma Dysregulation Mindfulness Attunement Attachment

12. Deep History of the Brain For millions of years of human evolution our brains adapted to an unchanging economy-hunting/gathering-For millions of years of human evolution our brains adapted to an unchanging economy-hunting/gathering- Our limbic system evolved to create fear, anxiety and aggression to meet the requirements of the fours “F”s: Fight, Flight, Feed, ReproductionOur limbic system evolved to create fear, anxiety and aggression to meet the requirements of the fours “F”s: Fight, Flight, Feed, Reproduction Anxiety and fear were necessary for daily survival. Our vigilance andAnxiety and fear were necessary for daily survival. Our vigilance and emotions were finally tuned to our environment. Our hunter/gatherer economy endured for the vast majority of human history. It is just in the last 10,000 years that agricultural technologyIt is just in the last 10,000 years that agricultural technology evolve to create enough surplus that humans changed from evolve to create enough surplus that humans changed from small bands of hunter/gathers into sustainable larger groups and civilization started to form. This very recent development moved fast and created anThis very recent development moved fast and created an adaptive lag for our brains to struggle to compensate. Neurosis is that struggle and culture can be seen as our attempt to adjust.

13. The whole is greater than the sum of the parts Each part is highly influenced by the processes and current state of the whole brain. A minor change in a person’s state or environment can produce vastly different neural patterns.

15. Newborns are born with twice as many neurons as adults. Within an hour after birth, the infant starts to imitate the expressions of those around them and prefer the configuration of the human face to any other visual stimuli. (Meltzoff and Moore, 1977). Failure to Thrive: children can die from not being touched, spoken to, looked at, etc. Even if their basic needs are attended to, the studies of Romanian orphanages showed that children died due to the lack of human attachment (Spitz). Human babies are designed to attach to caregivers. Babies are designed to attract the kind of attention needed to survive. Whatever neurological structure they bring into the world immediately begins interacting with, and is changed by, the environment. The Brain Development

16. Facial expressions to communicate core emotions- anger, fear and approval are the same in every culture and every human being. We later learn the emotional display rules in our particular culture. (Ekman 1993). Watching the face, listening to the emotional timbre of vocalizations, and using subtle olfactory cues, mother and infant together begin building attunement and shared emotional regulation. The “affective attunement” is contingent on the parent’s capacity to provide a secure base and a holding environment so that the infant feels connected and also responded to as a separate subjective being (Siegel, 1999, Siegel & Hartzell, 2004, Trevarthen, 1993). The key is recognizing and responding to each other’s emotions.

17. “love is simply the brain’s way of nurturing another brain.” Conversely, prenatal stress is associated with medical problems, hyperactivity, irritability, language deficits & lower IQ in baby. The cause is elevated cortisol levels that in effect “corrode” the developing brain.( Brizendine, 2007- Pregnancy changes). Genes do not determine behavior they increase the probability of certain behaviors developing. Genes interact with the environment and can be turned on or off by exposure to the environment. (see Epigenetics)

18. The Prefrontal Cortex and Self-Regulation Regulation of the body Regulation of emotion Emotionally attuned interpersonal communication Response flexibility Self-awareness Autobiographical memory Self-soothing abilities Intuition Morality Nine Functions of the Pre-Frontal Cortex

19. Mirror neurons play a major explanatory role in the understanding of a number of human features, from imitation to empathy, and language learning. It has also been claimed that damages in these cerebral structures can be responsible for mental deficits such as autism.

20. The Neurobiology of Child Abuse - Martin Teicher The Scientific American March 2002 “Maltreatment at an early age can have enduring negative effects on a child’s brain development and function.” Patients with physical and sexual abuse reported symptoms of temporal lobe damage (specifically hippocampus and amygdala related) at a rate 113% higher than the control group. Hypothesis is that exposure to high levels of stress hormones (cortisol) in development can alter or kill neurons in the hippocampus and other limbic structures. Maltreatment before the age of 18 had greater impact than later abuse. Antisocial behavior resulting from child abuse appears to be caused by overexcitation of the limbic system, the primitive midbrain region that regulates memory and emotion.

21. The Neurobiology of Child Abuse - Martin Teicher The Scientific American March 2002 Summary: Limbic electrical irritability can produce symptoms of aggression, exasperation, anxiety, self-destructive behavior and increased risk for suicide. Reduced integration of right and left hemispheres and a smaller corpus collosum may predispose the emergence of borderline personality disorder.

22. Adolescence A period of biological, social, emotional and cognitive reorganization with the main goal of adapting to adulthood ( Susman & Rogel, 2004). 3 significant changes- 1.) Significant development of PFC 2.) Enhanced connectivity between parts of brain= increased white matter. 3.) Increase in synaptic pruning (cutting back unused neurons).

23. The adolescent brain The chemical messenger dopamine—a neurotransmitter inputs to the prefrontal cortex and grows dramatically during adolescence (a component of self-regulation). Increases one’s capacity to learn in response to reward— –reward signal becomes especially important in the prefrontal cortex as morality and judgment become increasingly reinforced and valued. Increase the capacity for more mature judgment and impulse control.

24. Adolescent MRI study When identifying emotions expressed on faces, teens more often activated their amygdala—the brain area that experiences fear, threat and danger— Whereas adults more often activated their prefrontal cortex —the area of the brain linked more to reason and judgment—and performed better on the task. Behaviorally, the adult’s responses were more intellectual, the teens’ more from the gut.

25. The pruning process has been described as a “massive loss of brain tissue”. (Paul Thompson, a member of the UCLA research team.) Tissue is lost at a rate of 1 to 2% per year. The pruning process is accompanied by myelination, a process in which the brain’s white matter, or “insulation,” focuses, refines and makes the brain’s operation more efficient. The pace and severity of these changes, which continue until one’s early 20s, have been carefully scrutinized by researchers. These changes mean that the brain is still developing.

26. The frontal lobe undergoes the most change during adolescence—by far. It is also the last part of the brain to develop Both the pruning and the insulation process are critical to the brain’s development. Insulation affects the speed and quality of brain activity (see Paus, et al.) while pruning and the development of gray matter contribute to overall cognitive functioning, including the ability to reason effectively. (see Casey and Reiss). Dr. Elizabeth Sowell, a member of the UCLA brain research team, has led studies of brain development from adolescence to adulthood (roughly ages 12 through 22).

27. A three dimensional “map” showing portions of gray matter “pruned” from the brain between adolescence and adulthood. The dark portions in the two boxes indicate those of the frontal lobe. The box on the far right indicates those of the part of the frontal lobe called the prefrontal cortex, the part of the brain that controls judgment. Image adapted from Nature Neuroscience.

28. Journal of Psychiatric Research 42 (2008) 167–183, Cerebral white matter deficiencies in pedophilic men James M. Cantor,*, Noor Kabani, Bruce K. Christensen, Robert B. Zipursky, Howard E. Barbaree, Robert Dicke, Philip E. Klassen, David J. Mikulis, Michael E. Kuban, Thomas Blak, Blake A. Richards, M. Katherine Hanratty, Ray Blanchard James Cantors research on Pedophilia and Cerebral white matter “… MRI research found a large region of low white matter volume relative to controls in samples of pedophilic men…they also show: show lower IQs, poorer visuospatial, poorer verbal memory scores, threefold higher rates of non- right-handedness, elevated rates of having suffered childhood head injuries resulting in unconsciousness, elevated rates of having failed school grades or having required placement in special education programs, pedophilic men are physically shorter than non-pedophilic controls suggesting that the poor white matter volumes may be one component of generally poor physical development.”

30. An Interpersonal Neurobiology - Daniel Siegel Basic Principles The mind is a process involving the flow of energy and information. The mind develops as the genetically programmed maturation of the brain responds to ongoing experience. The mind (energy and information flow) emerges in the transaction of neurophysiological processes and interpersonal relationships.

31. An Interpersonal Neurobiology - Daniel Siegel Convergence of neurobiology and attachment theory Human connections within relationships shape the neural connections of the brain from which the mind emerges. Relationships may not only be encoded in memory, but may also shape the very circuits that enable memory to be processed and self-regulation to be achieved.

32.   The right hemisphere of the brain is involved in self-soothing actions.   The left side is involved in more exploratory actions – an interpreter function.   Coherent narratives are a product of the integration of the left and right hemisphere processes.   The prefrontal region of the brain is a part of the integrated circuitry that permits social and moral behavior.. Interpersonal Neurobiology (Daniel Siegal)

33.   Impaired integration and self-regulation in the prefrontal regions can be seen within the brains of those individuals with unresolved trauma or grief.   Lower mode states ensue when the functioning of the integrating prefrontal regions become temporarily impaired.   Behavior is then driven by emotional states and impulses of the lower regions of the brain.   This creates a lack of experience integration and response flexibility, which is mediated by the orbito-frontal region of the prefrontal cortex. Interpersonal Neurobiology (Daniel Seigal)

34. Secondary Responses to Trauma 1.Depression 2.Aggression 3.Low Self-Esteem 4.Identity Confusion 5.Difficulties in Interpersonal Relationships 6.Guilt

35. Trauma can be conceptualized as stemming from a failure of the natural physiological activation and hormonal secretions to organize an effective response to threat. Rather than producing a successful fight or flight response the organism becomes immobilized. (Clinical Implications of Neuroscience Research in PTSD BESSEL A. VAN DER KOLK Boston University School of Medicine, The Trauma Center, 1269 Beacon Street, Brookline, Massachusetts, USA)

36. Exposed to traumatic reminders, subjects had cerebral blood flow increases in the right medial orbitofrontal cortex (Because of its functions in emotion and reward, the OFC is considered to be a part of the limbic system) insula, amygdala, and anterior temporal pole, and in a relative deactivation in the left anterior prefrontal cortex, specifically in Broca’s area, the expressive speech center in the brain, the area necessary to communicate what one is thinking and feeling. 1. RAUCH, S., B.A. VAN DER KOLK, R. FISLER, et al. 1996. A symptom provocation study of posttraumatic stress disorder imagery inVietnam combat veterans. Arch. Gen. Psychiatry 970–975. Q4 2. HULL, A.M. 2002. Neuroimaging findings in post-traumatic stress disorder. Br. J. Psychiatry 181: 102–110.

37. Children’s Brains Brain-Based Therapy with Children and Adolescents by Arden and Linford. All complex systems, including children’s brains require additional energy to change them. Resistance is not necessarily rebellious in nature, so much as the tendency for the system to remain in inertia and conserve energy (Grigsby & Stevens, 2000). Therapeutic process is a dialogue between the child’s existing ways of interpreting feelings and events and the therapists capacity to understand and interpret these. It is also a bond that changes the brains of both parties.

38.   The mind continues to develop in response to emotional (intimate) relationships throughout the lifespan.   The treatment approach for trauma requires the ability to engage in attuned collaborative communication. Interpersonal Neurobiology (Daniel Siegal ) Trauma recovery

39.  5 Basic elements of Secure attachments: 1. Collaboration- attuned communication builds a coherent core and autobiographical sense of self. 2. Reflective dialogue- share internal experiences 3. Repair- when attuned communication is disrupted, as is inevitable, repair of the rupture is important in reestablishing the connection. Prolonged disconnection has a negative effect on a child’s sense of self. 4. Coherent Narrative- allows integration of experiences 5. Emotional communications- allows to reduce, regulate and sooth negative emotional states. Interpersonal Neurobiology Interpersonal Neurobiology Daniel J. Siegel, MD, “Toward an Interpersonal Neurobiology of the Developing Mind: Attachment Relationships, Mindsight, and Neural Integration” in Infant Mental Health Journal, 2000.

40.  The Relational Models examine the interpersonal realm of experience throughout development and the role attachment plays (rather than intrapsychic conflicts) in the development of a sense of self/and stable self-esteem.  To victimize another is a narcissistic act – a devaluing of another. The formation of a narcissistic relational style can be seen as a defense against a fragile self-esteem and a vulnerability to shame.  The study of Narcissism, pioneered by Kohut, organizes much of the understanding about sexually deviant behavior by suggesting that: Traumatic disruptions in early attachments derails the development and regulation of self-esteem and the formation of intimacy. Object Relations Theories

41. Relational Models Attachment and Intimacy Self-esteem Narcissism

42.   The concept of “psychological deep structure” suggests that human psychology formed from primal selective pressures that favored those individuals who are able to think, feel, and behave in ways that supports the survival of themselves, their offspring, and their extended family.   Inclusive fitness is more adaptive than survival of the fittest individual   These deep structures such as compassion, sympathy, shame, guilt, and anxiety evolved to support and regulate the primal human requirement of being attached to others. (Kriegman D. & Slavin M. 1992).   Bowlby’s research: “….the core of all psychological defenses is an attempt to deactivate of the need for attachment (Bowlby, 1980). Evolutionary Psychology

43. Research on trauma/resiliency found that a secure attachment can mediates the effects of childhood sexual abuse. (Shapiro D; Levendosky A., 1999) Strong attachment to at least one parent was found to significantly reduces the risk of delinquency in children. This study showed that single parent families were not associated with delinquency as long as the child was strongly attached to the custodial parent (Rankin, J.; Kern, R. 1994) Caretaker inconsistency was found to be related to sexual violence. Caretaker abuse was found to be related to general violence. (Prentky)

44.  Mutual self disclosure in relationships  Warmth and affection between partners  Closeness and interdependence between partners (Marshall,‘89;Weiss, ‘73)  Bonding between two people based on trust, respect, love, and ability to share deeply (Bass and Davis ‘88) Definitions of Intimacy ( Ward, McCormack, Hudson,1/97 Sex Abuse Journal, “ Sex offenders perception of their Intimate Relationship ” )

45. Benefits of Intimacy (Fehr and Perlman, ‘85) Resiliency to stress Increase in self-esteem Improves physical and mental health

46. Early attachment deficit disrupts an individuals ability to regulate the stress created by strong negative affect in particular the regulation of self-esteem or shame. Shame is a primal fear, a disintegration of one’s sense of self, and the strongest negative emotion. (James Gilligan, Violence: Our Deadly Epidemic)

47.   For those with resilient self-esteem, an assault to one’s sense of self is managed by turning to the people and things we love, for reassurance and a sense of connection (Spencer, Josephs, Steele, 1993).  Without the resiliency that attachments and intimacy affords, to mitigate the depleting effects of a narcissistic injury, sexually exploitative behaviors becomes an attempt to extort intimacy when it can’t be achieved through affiliation (Anechiarico 1998).

48. Sex offenders have fragile and unstable self-esteem rather than simply low self-esteem  “...Self-esteem instability, was related to greater anger and hostility proneness.  Unstable high self-esteem individuals reported the highest tendencies to experience anger and hostility.  Anger and hostility are often instigated by self-esteem threats of an interpersonal nature, such as insults or criticism.  Anger and hostility serves to defend against negative self- feelings and restoring one’s damaged self-esteem...” (Kernis, M., “ The Roles of Stability and Level of Self-Esteem in Psychological Functioning) Self-Esteem

49. Sexual exploitation is an emotional response to:  A deprivation of intimacy  Absence of sexual gratification  Powerlessness and loss of control   Lack of self-confirmation There was a statistically significant reduction in deviant arousal measured phallometrically when sex offender treatment targeted self-esteem.  Emotional intimacy  Empathy  Sense of accomplishment  Self-affirmation Reseach on the Motivation of Sexual Deviancy Reseach on the Motivation of Sexual Deviancy [1995 by W. Marshall]

50. In Hudson and Ward (1997) applying Bartholomew and Horowitz’s study of attachment found:   Securely attached individuals (+/+) have high levels of self-esteem and view self and others generally positively and experience high levels of intimacy.   Preoccupied individuals (-/+) generally view self as negative and others positive. They are sexually preoccupied and prone to sexualizing their need for security and affection.   Fearful individuals (-/-) have a negative view of self and others and desire social contact but avoid interactions and have a passive-aggressive personality style.   Dismissing individuals (+/-) have a positive view of self and negative view of others and have a narcissistic personality style with a tendency towards overt anger and hostility towards others (Bartholomew, K., & Horowitz, L. M, 1991).

51. Child molesters (-/+) were more likely to have a more preoccupied or fearful attachment style than rapists and to be less dismissive.   Rapists (+/-) were undifferentiated in some respects from violent non-sex offenders (i.e., both tended to be dismissive). Non-violent non-sex offenders were comparatively the most securely attached. [Ward T; Hudson S; Marshall W. (1996). Attachment style in sex offenders: a preliminary study. The Journal of Sex Research, v33 n1, p17.]  Ward, Hudson and Marshall (1996) found that the majority of sex offenders they studied were insecurely attached. They also found this to be a general vulnerability factor for other incarcerated offenders as well as for sex offenders.

52. Child molesters were more likely to engage in emotion- focused coping strategies. Types of coping strategies ( Endler, Parker ’90 ):  Problem-focused coping (direct efforts to resolve problems) is predictive of positive adaptation  Emotion-focused coping (attempts to diminish emotional distress or engaging in daydreaming)  Avoidance-focused coping (social diversion or distraction) Last two produce negative consequences, including depression, anxiety, and greater distress.

53.   S.O. when stressed with negative emotions will adapt a state of Cognitive Deconstruction (Ward, Hudson, Marshall ’95): pursuit of immediate gratification of needs without regard for the more abstract long-term consequences. Fantasy- direct behavior and emotion- focused coping.   Interpersonal conflict and negative emotional states led to an increased tendency among sex offenders to engage in deviant masturbatory fantasies. (Proulx, 94, 96) Childhood Attachments and Adult Coping in Child Molesters (W.L.Marshall, Geris A. Serran, Franca A. Cortoni; Sexual Abuse vol.12, no.1, 2000)

54.  This perspective offers a view of sex offending as not only a behavior disorder but is also a relational disorder and that the aim of the behavior can be seen as a narcissistic attempt to restore vitality to a shamed or damaged sense of self. With this understanding, sexual offending can be seen as an extortion of intimacy—stealing a connection to another to stabilize a damaged self-esteem. Object Relations Theories

55.  The Relational Models examine the interpersonal realm of experience throughout development and the role attachment plays (rather than intrapsychic conflicts) in the development of a sense of self/and stable self-esteem.  To victimize another is a narcissistic act – a devaluing of another. The formation of a narcissistic relational style can be seen as a defense against a fragile self-esteem and a vulnerability to shame.  The study of Narcissism, pioneered by Kohut, organizes much of the understanding about sexually deviant behavior by suggesting that: Traumatic disruptions in early attachments derails the development and regulation of self-esteem and the formation of intimacy. Object Relations Theories

56. Stage 1: Preliminary Diagnosis of Relational Pattern Stage 2: Building the Therapeutic Alliance Stage 3: Identifying the Maladaptive Relational Pattern Stage 4: Patient Expresses Maladaptive Pattern Stage 5: Therapist Generates Empathic Confrontation Stage 6: Working Through the Confrontation Stage 7: Generalizing the Therapeutic Relationship Stage 8: Separation and Termination Thomas Klee, Ph.D.

57. Early attachment deficit disrupts an individuals ability to regulate the stress created by strong negative affect in particular the regulation of self-esteem or shame. Shame is a primal fear, a disintegration of one’s sense of self, and the strongest negative emotion. (James Gilligan, Violence: Our Deadly Epidemic)

58.   For those with resilient self-esteem, an assault to one’s sense of self is managed by turning to the people and things we love, for reassurance and a sense of connection (Spencer, Josephs, Steele, 1993).  Without the resiliency that attachments and intimacy affords, to mitigate the depleting effects of a narcissistic injury, sexually exploitative behaviors becomes an attempt to extort intimacy when it can’t be achieved through affiliation (Anechiarico 1998).

59. The pursuit of attachment is more fundamental in human motivation than sexual and aggressive drives. When attachments break down, sexual and aggressive impulses take over. Kohut (1997) formulates that the basic striving in human development is towards attachment to others and that there is no self without another.

60. There is a drive to be seen as important and affirmed by someone who is admired and represents the ideal self. Exhibitionism/Grandiosity : Talents & Skills Idealization : (seeking mirroring & affirmation) (seeking guidance, protection,inspiration) The Development of a Sense of Self

61. There is a drive to be seen as important and affirmed by someone who is admired and represents the ideal self. Exhibitionism/Grandiosity: talents & skills Idealization: (seeking mirroring & affirmation) (seeking guidance, protection, inspiration) Optimal Response: The needs of the self are met in a relational context and a sense of self is internalized Pride in accomplishments Ideals Assertiveness  Security Mastery OR Self-worth Confidence  Ambition The Development of a Sense of Self

62. There is a drive to be seen as important and affirmed by someone who is admired and represents the ideal self. Exhibitionism/Grandiosity: Talents & Skills Idealization: (seeking mirroring & affirmation) (seeking guidance, protection, inspiration) Optimal Response: The needs of the self are met in a relational context and a sense of self is internalized Pride in accomplishmentsIdeals Assertiveness  Security Mastery OR Self-worth ConfidenceAmbition Traumatic Disruption: The needs of the self are withdrawn from a relational context and a sense of self remains externalized. Primitive Exhibitionism:Primitive Voyeurism: Sexual violence, aggressiveness, Externalize idealization, abuse of power and control, rage. sexualization of love & entitlement. affection from children. As our children look to us with wide -eyed admiration for affirmation of their newly found skills and abilities, we respond with joy and pride. With an optimal response that pride is internalized and a resilient sense of self is established. A traumatic disruption in this process results in a withdrawal of the needs of the self from a relational context leaving the sexual and aggressive drives to be expressed in primitive exhibitionistic and voyeuristic ways. Development of the Self

63.   Bring needs of the self into the context of an intimate relationship.  Attunement /empathy addresses the need for sexually exploitative behavior.  Listening, understanding, and “self affirming” responses builds the relational field. Restoration of Self-esteem

64. “Adequate nurturing and the absence of intense early stress permits our brains to develop in a manner that is less aggressive and more emotionally stable, social, empathic, and hemispherically integrated. We believe that this process enhances the ability of social animals to build more complex interpersonal structures and enables humans to realize their creative potential.” Martin Teicher The Scientific American March 2002

65. Relational principles in the treatment of pathological narcissism: Schema Therapy with Jeffrey E. Young Washington, DC: American Psychological Association, 2007. American Psychological Association Videotape Series I, Systems of Psychotherapy, “…there is a need for attunement, reflection, empathy, and clarification even as the focus of the therapy remains on the client's destructive and pervasive maladaptive schemas.”

66. There are four main types of skills in DBT skills training. 1. Mindfulness Meditation Skills. These skills center on learning to observe, describe and participate in all experiences (including thoughts, sensations, emotions and things happening externally in the environment) without judging these experiences as "good" or "bad." 2. Interpersonal Effectiveness Skills. The focus of this skill module is on learning to successfully assert your needs and to manage conflict in relationships. 3. Distress Tolerance Skills. Accept and tolerate distress without doing anything that will make the distress worse in the long run (e.g., engaging in self-harm). 4. Emotion Regulation Skills. Identify and manage emotional reactions. Dialectical Behavioral Therapy

67. Attachment –Based Treatment (Phil Rich) Build a secure base Confidence in connections based on consistency Coherent sense of self Balance of affective and cognitive problem solving Cooperative and non-coercive strategies for get needs met Frustration tolerance Empathy for others Moral understanding and moral reasoning Experience connection and relatedness to others

68. Goals of Attachment-based treatment Self-regulation, self efficacy, security –This is achieved in treatment through: Empathic attunement Affirmation of the clients strengths Provide role models View irrational behaviors as insecure attachment strategies –Milieu: Attachment-informed treatment environment Facilitative climate

69. Risk Management versus Good Live Risk Management strategy Avoid contact with children Leaves a void in the offenders life Good Lives strategy Look at ways to develop appropriate attachments and intimacy e.g. sexual knowledge training, relationship skills Engagement in appropriate activities that promote self- worth, e.g. work, school, skills and talents Must be realistic (e.g. trying to develop intimacy may not be the first step, but developing friendships would

70. In Daniel Siegel’s (2007) work on Mindfulness and emotional regulation. 1.“We create nonreactivity by developing the circuits in our brain than enable the lower affect-generating circuits to be regulated by the higher modulating ones…..this is called “response flexibility” The way that we pause before action and consider the various options that are most appropriate before we respond. 2.States of “mindfulness”, can be achieved when we coordinate our autonomic systems with our intentional systems. For example breath awareness can create a state of mindfulness that leads to emotional regulation, emotional integration and ultimately resiliency. 3.While an intimate interconnection to others helps with emotional regulation, an intimate intra-connection between our brains and minds can directly impact emotional regulation also.

71. Judith Herman recognized three general stages of recovery from trauma. 1. 1. Central task of the first stage is to establish safety. 2. 2. Central task of the second stage is remembrance and mourning. 3. 3. Central task of the third stage is reconnection…” (Trauma and Recovery1992)

72. Sexual violence and sexual exploitation can be seen as a symptom of : A Trauma Disorder creating an Attachment Disorder manifesting symptoms of a: Behavior Disorder Behavior Disorder Cognitive Disorder Cognitive Disorder Emotional Disorder Emotional Disorder Character Disorder Character Disorder Neurological Disorder Neurological Disorder Elements of Sex Offender Treatment and Management

73. END OF PART I

74. Part II MOTIVATIONAL INTERVIEWING & ENGAGEMENT

75. An Introduction to Motivational Interviewing David S. Prescott, LICSWAutumn2007With gratitude to Bill Miller, Steve Berg-Smith, Lorraine Reitzel, and Therese Kemper

84. Correlates of Client Change Talk

85. Correlates of Client Resistance

86. Summary Increasing client change talk (particularly commitment language) promotes behavior change Stated implementation intentions predict behavior (Gollwitzer) Client resistance fosters no change Thus: Elicit and reinforce change talk, not resistance

87. Findings that preceded MI: The work of Carl Rogers Counselors are a major determinant of client change Counselor empathy predicts client change outside of MI Small acts of caring can strongly impact outcomes

88. Unexpected Findings Moyers, Miller & Hendrickson, JCCP, in press Counselor use of MI-consistent spirit and practices is positively associated with behavior change Within MI, modest counselor use to confront responses is also positively associated with behavior change but if and only if the counselor also manifests the spirit of MI (empathy, etc.)

89. Clinical/Training Implications First and foremost, manifest and practice the overall spirit of MI Helping the client to develop and verbalize arguments for change increases the likelihood of change Helping the client when ready to develop a specific change plan also increases the likelihood of change

90. The most significant factor in a client’s change process are the Therapist’s characteristics. Numerous research studies have found that Therapists that are caring, empathic, interested in the client’s growth and progress, and genuine are the most effective change agents.

91. END OF PART II

92. PART III CLIENT CENTERED THERAPY: EFFECTIVE GROUP FACILITATION & DEVELOPING GROUP CULTURE Timothy L. Sinn, LMHC Chief of Clinical Services

93. Differences in Treating Sex Offenders Traditional Mental Health Treatment Sex Offender Treatment See Patient as suffering from an illness- not responsible for behavior See participant as responsible for behavior SupportiveConfrontive (not shaming) Trusts PatientsAlways questions information Allows patient to set agendaTherapist sets agenda Follows patient’s valuesTherapist imposes values Patient welfare is first concern Public safety is first concern Complete confidentialityLimited confidentiality Patient is accountable to selfClient is accountable to society

94. THE GROUP SPACE Do’s & Do not’s

95. DO’S and DO NOT’S BEGIN session on time….END session on time. Be prepared for group. Have a session agenda prepared, have sign-in sheets prepared, have receipts filled out and ready to go. Be respectful, firm, empathic, engaging, caring, and responsive. The group members needs to be very involved. The therapist is a facilitator, not an individual therapist within a group.

96. Do’s and Do not’s Identify expectations and goals of treatment. Engage and include clients in treatment planning. Keep the CYCLE as a focus… the goal is to utilize interventions, to develop healthy connections, to remain stable. Probation/Parole Victim Advocates, and Polygraphers are our partners in clients being successful. Here and now issues are a central focus.

97. Do’s and Do not’s Share only minimal personal information. Do not buy alliances. DO NOT share issues that the clients must hold for you. This is their treatment, not yours. Do not eat in group. If you express anger, sadness, etc….this should be a planned treatment intervention…know thyself. Encourage group to support one another.

98. Do’s and Do not’s Dress appropriately. Use appropriate language. Avoid back to back group days for High Intensity Treatment (twice per week). When a client misses a group, P.O. is notified of the absence immediately or within 24 hours.

99. If a client misses a group, they do not attend a make-up session. No Group Hopping-destroys cohesiveness and trust. If you don’t feel that the group should be a sacred, safe, personal space, with boundaries, neither will the clients. Model what is healthy. Other Do’s and Do Not’s

100. ESTABLISHIN G THE TREATMENT ENVIRONMEN T

101. THE TREATMENT ENVIRONMENT The Group space needs to feel and be safe. The Group space needs to be a place for trying out new behaviors. Begin group with a 10 minute relaxation exercise, breathing, mindfulness experience (brain-based). Think outside the box…create an environment that is serious, yet provides a comfortable environment for change.

102. TREATMENT DELIVERY

103. Group Therapy (continued)

104. CLOSING GROUP

105. CLOSING End group on time. Make a closing statement about the group process. Identify any remaining issues that will be picked up at the next session.

106. END OF WORKSHOP Thank You