1Jan Looman, Ph.D., C.Psych. Kingston, Ontario Jan1looman2@yahoo.ca Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for CliniciansJan Looman, Ph.D., C.Psych.Kingston, Ontario
2Assessment 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
3OutlineModels of Treatment - RNR vs. GLMDescribe triage process for sex offenders in Ontario/CanadaWhat do I mean by “high risk/needs”?Describe treatment process for High Risk/Needs Sex OffendersLink to community treatment – continuity of care
4Models of Treatment What really is RNR? RNR vs. GLM Is the Good Lives model different?Before we go on to discuss treatment itself I think an explication of our treatment model is required. Lately there has been a lot of fuss in the literature and at conferences regarding the GLM with claims being made that it is a vast improvement on existing treatment models.But is it?
5Models of TreatmentRNR 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.
6Models of TreatmentGPCSL posits that crime results when the personal, interpersonal, and community supports for behavior are favorable to crimeStrong influences - antisocial attitudes, antisocial associates, a history of offending, antisocial personality traits.Weaker influences - familial difficulties, poor adjustment to work and school.Possessing antisocial attitudes and having antisocial associates are considered particularly strong influences, as is a history of offending and antisocial personality traits. Weaker influences include familial difficulties and indicators of social achievement, such as work and school. Therefore, the GPCSL takes a broad perspective, recognising that personal, interpersonal, and social factors are involved in the acquisition and maintenance of criminal behavior
7Models of TreatmentRNR Principles – guide us in designing intervention within the GPCSL theoryThe 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 riskSo in keeping with this principle we use structured risk assessment tools such as the Static-99R or the SORAG to determine who we provide treatment
8Models of TreatmentThe 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.Important to note that Hanson’s meta analyses have linked these to all types of recidivism, so they are valid targets for SO treatment
9Models of TreatmentSex offender specific criminogenic needs identified by Mann, Hanson & Thornton (2010)Sexual preoccupationSexual deviance – esp. deviant arousal to children; multiple paraphiliasOffense-supportive attitudesEmotional congruence with children
10Models of Treatment Sex offender specific criminogenic needs (con’t) Lack of emotionally intimate relationships with adultsLifestyle impulsivenessPoor problem solvingResistance to rules/supervisionHostilityNegative social influences
11Models of TreatmentOther factors identified as “Promising” criminogenic needs:Hostility toward womenMachiavellianismLack of concern for othersDysfunctional copingSexualized copingExternalized copingMach. - personality is characterized by manipulation and exploitation of others, with a cynical disregard for morality and a focus on self-interest and deceptionLack of concern for others = PCL-R facet 2 - described as selfish, cynical, and willing to be cruel to meet their own needs. They appear indifferent to other people’s rights or welfare, except as it influences their own interests.
12Models of TreatmentNon –Criminogenic Needs Hanson & Morton-Bourgon (2005)Force/violence in sex offendingNeglect or abuse during childhoodSexual abuse during childhoodLoneliness*Low self-esteemLack of victim empathyDenial of sexual crime *Low motivation for treatment at intakePoor progress in treatment (post)Loneliness has been found in the DSP to be related to recidivism but other studies notRecent research has found that denial is related to recidivism for some offenders – I’ll go in to that more laterIt is possible that much of what passes as poor victim empathy could be better construed as justifications that offenders used to distance themselves from a deviant identity. It is also plausible that for some individuals poor victim empathy may be a symptom of the more general problem of lack of concernfor others (see above).Re: neglect/abuse/sexual abuse in childhoood – recent research (Jesperson, Lalumiere & Seto, 2009) shows higher rates of sexual abuse in sex offenders and other research (complex PTSD, Courtois, Ford & Herman, 2009) shows that childhood trauma is associated with a variety of negative outcomes. However, the research suggests that these may lead to the development of problematic behaviour but they are not related to the maintenance of it.
13Models of TreatmentWithin the Need Principle non-criminogenic needs not relevant targets for interventionA 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)
14Models of Treatment The Responsivity Principle general - the most effective interventions tend to be those based on cognitive, behavioral, and social learning theoriesthe relationship principle (Andrews, 1980) (establishing a warm, respectful and collaborative working alliance with the client) and,the structuring principle (influence the direction of change towards the prosocial through appropriate modeling, reinforcement, problem-solving, etc.)Note – in 1980 Andrews identified the importance of the therapeutic relationship in affecting change in antisocial attitudes among inmates – randomly assigned probationers to officers who were rated on their warmth, empathy, and interpersonal skills – lower recidivism rate and greater attitude change associated with the more skilled officers
15Models of Treatment The Responsivity Principle 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 treatmentHere you may have to address mental disorders, anxiety, introduce interventions to accommodate a learning disability etc.Present material appropriate for the audience – reading level, visual vs. language based
16Models of TreatmentResponsivity Factors (Looman, Dickie & Abracen, 2005; Olver, Stockdale & Wormith, 2011)psychopathyLow motivation/ denial/minimizationlow intellectual functioning/lack of educationhostile interpersonal style/disruptiveMental health difficultiespersonality profileHere you may have to address mental disorders, anxiety, introduce interventions to accommodate a learning disability etc.Present material appropriate for the audience – reading level, visual vs. language based
17Models of Treatment Summary RNR Treatment directed toward higher risk clientsAddresses known criminogenic needsCognitive behavioural/social learning approachesEmphasis on effective therapist characteristics and role modeling delivered in a manner appropriate for the client group
18Evidence for RNRDowden and Andrews (1999) - meta-analysis of 25 studies of treatment for female offenderseffect 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.any treatment programming significantly stronger effect than criminal sanctions alone
19Evidence for RNRDowden and Andrews (2000) - meta-analysis 35 studies of treatments for violent offenderscriminal sanctions alone no effect on recidivismany human service delivery significant positive effect.programs which adhered to RNR principles were more effective than those which did notPrograms targeting criminogenic needs associated with a moderate effect size - those which did not produced no significant reduction in recidivism.
20Evidence 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).So as the number of noncriminogenic needs targeted increases, the effect sizes decreases
21Evidence for RNRHanson, et al. (2009) studies of sexual offender treatmentadherence to the RNR principles greater reductions in recidivismeffect was linearly related to the number of RNR principles adhered to.programs which adhered to none of the principles a negative treatment effect.
22Evidence for RNRDowden, 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 programsCoded 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)
23Evidence 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.
24Evidence for RNR Summary Treatment approaches which adhere to RNR principles effective in reducing recidivism for violent offending, female offenders, sexual offendersRP approaches which adhere to RNR principles also effectiveApproaches which focus on noncriminogenic needs (for SOs internalizing psychological problems denial, low victim empathy, and social skills deficits) non-effective or even harmfulNote – didn’t review research related to general (any) recidivism but the results are the sameInternalizing – depression, anxiety
26Good Lives Model Assumptions about Human Nature Assumes all human being are practical decision-makers and have similar aspirations and needsone of the primary responsibilities of parents/teachers to equip people with the skills/tools to make their own way in the world
27Good Lives Model Assumptions about Human Nature (con’t) People formulate plans and intentionally modify themselves and their environment in order to achieve goalsIn order for people to function effectively their basic needs must be met
28Good Lives Model Assumptions 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 reproducePeople 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 identityPHG =basic human needsSecondary good – the means of achieving the primary good – e.g. good of relatedness= desire to form warm affectionate bond with someone else – secondary good = friendships
29GLM on RNR Criticize RNR approaches focus on risk reduction/management unlikely to motivate offenders – need to have approach goalspay attention to offender as a whole - RNR sees offender as “disembodied bearer of risk”Lack of focus on non-criminogenic needs – therapeutic relationshipRNR approaches “one-size fits-all”Point # 2Related to this is a lack of appreciation for personal choice in setting treatment goals and the importance of gearingtreatment to the needs and interests of offenders while still modifying their level of risk. Thus, the claim is that the RNR model does not pay enough attention to the role of personal or narrative identity and agency (i.e., self‐directed, intentional actions designed to achieve valued goals) in the change process. This problem suggests that the RNR model lacks external consistency, unifying power, and practical utility (fertility).Point 3Claim that the RNR model suffers from a lack of explanatory depth and external consistency. Thiscriticism refers to RNR model's narrow view of treatment and a tendency to focus on a narrow set ofgoals relating to risk reduction.Does not acknowledge that rewards sought by individuals are at least partially determined by thebasic human needs and the goods (activities, experiences, objects) that satisfy them. If human beings do have anatural inclination to seek certain types of goods, then rehabilitation efforts should ensure that there is somerecognition of this fact and that attempts are made to facilitate (or at least not frustrate) their achievement.
30What 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);Laws & Ward (2011) say 10 – add community – sense of belongingInteresting – Laws & Ward say the list is extensive but not exhaustive while Ward & Marshall (2004) say the list of nine is comprehensive (i.e., complete)1. life (including healthy living and optimal physical functioning, sexual satisfaction); - physical needs and factors that are important for healthy living/functioning – food, water etc. – secondary good – exercise, diet-conscious, managing health problem2. knowledge; - people inherently curious and desire to understand themselves and their environment – secondary good = education, attending school, vocational training etc.3. excellence in play and work (including mastery experiences); - engage in leisure activity for it’s own sake – mastery in work-related or recreational activities – secondary – participating in sports, undergoing apprenticeship, hobbies, mentoring4. excellence in agency (i.e., autonomy and self-directedness); - the desire to be able to formulate ones own goal and act on those goal (master of one’s own domain) – secondary employment that allows autonomy, financial independence, asserting oneself, attempting to dominate others
31GLM Nine 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; and9. creativity.5. inner peace (i.e., freedom from emotional turmoil and stress); - emotional self-regulation ability to achieve emotional equilibrium secondary – engaging in balanced lifestyle, building positive relationships, learning emotional control, physical exercise, sexual activity6. relatedness (including intimate, romantic and family relationships) and community; - desire to establish warm affectionate bonds with others secondary – romantic relationships, friendships, spending time with friends, family7. spirituality (in the broad sense of finding meaning and purpose in life); - desire to discover and attain a sense of meaning and purpose in life – seeking religious truth/involvement, spiritual connect to transcendent being, or simply the sense of being a part of a larger whole – secondary – belonging to a church, practising religion8. happiness; - overall experience of being content and satisfied with one’s life – secondary – establishing relationships which lead to please, sexual partners, eating, playing sports fir pleasure9. Creativity – desire for novlety and innovation - work parenting, gardening, painting, playing an instrument
32GLM & OffendingCriminogenic needs = internal or external obstacles that frustrate and block the acquisition of primary human goodsIndividual lacks the ability to obtain the good in a prosocial manner and is unable to think about his life in a reflective manneri.e. criminogenic needs =deficiency in agency and conditions that that support agency
33GLM & Offending4 major difficulties with offender’s life plans that lead to offendingMeans he uses to secure goodsInappropriate strategies Violation of normsLack of scope – important good missing e.g., lack if connectedness feelings of loneliness/inadequacy
34GLM & Offending4 major difficulties with offender’s life plans that lead to offending (con’t)Conflict among goods sought – e.g. attempt to pursue good of autonomy leads to relationship issuesLack of capability – knowledge/skills deficits
35GLM & Offending Two routes to the onset of offending 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.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
36GLM & OffendingOffenders search for primary goods in their environments under the guidance and constraint of their practical identityAct in ways that they think will satisfy themSex offending arises because people make faulty judgementsLack of forethought or knowledge concerning relevant factsPractical identity – who they see themselves as – psychologist, father, scientiest
37GLM & InterventionShould be a direct relationship between goods promotion and risk managementRehabilitation = holistic reconstruction of the self new practical identityFocus on promotion of goods is likely to automatically eliminate or modify risk factorsAttitude of therapist – offender viewed as someone attempting to live a meaningful, worthwhile life in the best way he can in the specific circumstances confronting himAttitude – accepting, nonjudgemental
38GLM & InterventionTailoring of therapy to match the individual client’s life plan and their risk factorsTherapeutic task shaped to suit the person in questionFocus on approach goals rather than avoidance of risk factors
39GLM & Intervention Assumptions/Considerations (Laws & Ward, 2011) Offenders lack many of the essential skill/capabilities to achieve a fulfilling lifeCriminal 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.
40GLM & Intervention Assumptions/Considerations (con’t) Laws & Ward (2011)The absence of certain goods more strongly related to offending**:Self-efficacy/sense of agencyInner peacePersonal dignity/social esteemGenerative roles and relationships (work, leisure)Social relatedness (associates).Note: Laws and Ward (2011) make this claim but offer no research to support it – the first three are directly contradictory to meta-analytic research which I summarized earlier that demonstrates that these are not risk factors and that targeting them is inappropriate
41GLM & Intervention Assumptions/Considerations (con’t) Risk of offending reduced by assisting individuals to develop the skills/abilities to achieve the full range of human goodsIntervention = activity that adds to an individual’s repertoire of personal functioning rather than simply removing a problem or managing a problemNote: Laws and Ward (2011) make this claim but offer no research to support it – the first three are directly contradictory to meta-analytic research which demonstrates that these are not risk factors
42Evidence for the GLMLaws & Ward (2011) indicate (p. 202) that the GLM has empirical support – however they fail to offer any citationsThe area of positive psychology generally is empirically based however this cannot be taken as evidence that such approaches are effective with offendersE.g. Deci & Ryan (2000) - self-determination is positively correlated with personal well-being
43Evidence for the GLM Specific to Offenders? Case studies – which do not tell us whether or not effective in reducing recidivism or more effective in addressing criminogenic needsE.g. White, Ward & Collie, 2007 – Mr. C. gang member with long criminal history of violence including sexual violenceNoted that he had engaged in RNR based interventions on previous sentencesRemained in pre-contemplation and rigid antisocial attitudes, continued drug useDid not see how the material from the programs applied to him – gang identified
44Evidence for GLM Mr. C. (con’t) Treatment according to GLM Outcome – 14 months following releaseDisclosed 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 effectPhase 1 – personal visualization of a new me – future focus- university, obtain a drivers license, improved intimate relationships, make family proudPhase 2- in order to accomplish reduction in drug use, prosocial peers, prosocial attitudes, detachment from gangPhase 3e.g. Mr. C pursuit of the primary human goods of happiness, friendship, and intimacy through the secondary goods of his gang membership, associated violence, substance abuse, and predatory sexual behaviour. - access to his primary human goods of happiness,friendship, and intimacy were blocked (i.e., prevented) by his criminogenic needs (i.e., violence propensity, offence-related sexual arousal, relationship difficulties, substance abuse, employment instability, antisocial beliefs, and criminal companions).Phase 4equipping individuals with the skills, values, attitudes, and resources necessary to lead a different kind of life that is highly valued by each individual and one that does not involve inflicting harm on themselves.Phase 5goal attainment and to monitor progress via regular supervision.
45Evidence for the GLM Specific to Offenders? Harkins, Flak, Beech & Woodhams (2012)76 men who participated in GLM based community SO treatment701 who participated in an RP oriented treatment
46Evidence for GLM Harkins et al.(2012) (con’t) pre-post treatment psychometric assessment – measures which previous research demonstrated associated with recidivismAttrition ratesFacilitators perception of the program and offender’s motivationOffender’s perception of the program
47Evidence for GLM Harkins et al.(2012) (con’t) Attrition rates did not differ significantlyNo difference in rates of change on psychometric measuresFacilitators liked the GLM-based module63.7% did not think it would be appropriate for high-risk/unmotivated clients
48Evidence for GLM Harkins et al.(2012) (con’t) Clients rating of improved understanding of their offending - 80% of RP group compared to 46% GLMbetter understanding of the positive aspects of themselves 61% for GLM compared to 20% for RP
49Evidence 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 modulethoughts and attitudes about themselves or the future were more positive - 47% for GLM vs. 20% for the RP module.
50Evidence 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 strategiesOpposite was true for RP/RNR based programno differences overall in terms of attrition or change on risk factorsNoted that more recent revisions of the module include greater focus on risk factors
51GLM 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 goodsRNR approach: crime results when the personal, interpersonal, and community supports for behavior are favorable to crime
52GLM vs. RNRRNR focuses on the Central Eight -addressing such needs as lack of education and employment and lack of supportive, rewarding, and prosocial familial and marital relationshipsGLM identifies 9 “goods” with a great deal of overlap with the Central eight
53GLM vs. RNR GLM goods RNR Central Eight Knowledge Excellence in Play and WorkAutonomyInner peaceRelatedness/CommunitySpiritualityHappiness/CreativitySchooling/EmploymentEmployment/leisureEmployment/cognitions/attitudesAntisocial cognitions; antisocial personality patternAssociations/Family maritalAntisocial attitudesLeisure/work/family/associatesAutonomy = the desire to formulate ones goals and seek ways to realize them without undue interferenceseeking employment, financial independence, assertionInner peace – emotional regulation, positive relationshipsHappiness/creativity related to doing things that you enjoysuch as sports, sex
54GLM 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 orientedAndrews & Bonta(2010) discuss the importance of prosocial skills building and role-modeling by treatment providers
55GLM vs. RNRWormith, 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 semanticBut in reality RNR focuses on skill building and attitude change in order to address the criminogenic need much as GLM does
56GLM vs. RNRThe need to use approach goals and positive language is a contribution – field too often focused on negativeNo evidence this leads to greater benefit from treatmentBut in reality RNR focuses on skill building and attitude change in order to address the criminogenic need much as GLM does
57RTC Sex Offender Program Triage ProcessWhat do I mean by High Risk/NeedsRTC program
58Triage Process in Ontario RTCSOTP in operation from 1972 to 2011Only institutional sex offender program in Ontario until 1989WSBC initiated at that time1992 Sex Offender Assessment Team established at the Millhaven Assessment Unit
59MAU AssessmentMAU Sex Offender Assessment team assesses all sex offenders entering the Federal prison system in OntarioIn Canada sentence 2+ years served FederallyAssessment addresses level of risk (actuarial) and treatment needs
60MAU Assessment (con’t) Initially used PCL-R, SORAG, LSI-R, RRASOR and case historyadded Static-99/STABLE when availableDropped PCL-R/SORAG in 2002
61MAU Assessment (con’t) developed first National Standards for sex offender treatmentestablished Low, Moderate and High Intensity designations
62Intensity LevelsWith Standards we (i.e., regional sex offender program directors) adopted these levels of intensityRTCSOTP=highWSBC=moderateBath (est. ~ 1992) low-moderatelate 1995 RTCSOTP focus on high risk, high treatment needs offenders
63Intensity 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.)
64Moderate WSBC HISOP RTC** MAU **Low PittsburghLow-Mod BathNote Low intensity program discontinued 2010, RTC program discontinued in 2011Now the Moderate and High programs are both instutionally based
66RTCSOTPDescription of the ClienteleProgram ComponentsOutcome data
67Actuarial RiskThis table shows the scores on various actuarial risk assessment tools for RTC sex offenders compared to the data reported by Calvin Langton, in his PhD thesis, for men assessed for the WSBC. As can be seen, the RTC guys score higher, by about 1 sd, on every measure. As a further comparison, the average score for RTC offenders on the VRAG is at the 76th percentile for the norms published by Quinsey et al (1998). The SORAG score is the 80th percentile.
68Changes over TimeThis slide shows the changes over time in terms of scores on the actuarial instruments. As can be seen, comparing more recent admissions, after the focus on high risk/needs offenders occurred, to those assessed in the early 90’s, a much higher percentage of offenders fall into the high risk category. The PCL-R high risk refers to total scores over 29. Using a cut-off of 25, 49% of our clients are in the high-risk range.
69Program Differences Note: aHi intensity differs from Moderate HiModLo-ModLoLSI-R b25.121.917.310.3Static-99a22.214.171.124.6STABLEa9.57.04.83.5Note: aHi intensity differs from ModeratebHi intensity same as moderate but different from other groups
70DiagnosisFinally, use DSM diagnoses to determine the presence of increased responsivity needslooked at 48 consecutive admissions to the SOTP (in 2005)37 (77.1%) meet criteria for a personality disorder15/37 (40.5%) have personality orders described as “severe” by the diagnostician (e.g., BPD, Narcissistic, psychopathy)
71Diagnosis (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
72Diagnosis (con’t)22 (45.9%) met the criteria for a paraphilia, most often sexual sadism or pedophiliaNine of these 22 (41%) also meet criteria for severe personality disorder – typically psychopathy or borderline
73Deviant 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)Used to use slide assessment up to about 2001 but dropped it
74Deviant Arousal40% of adult rapists deviance on adult sexual violence assessment92% of child molesters deviant on child sexual violence assessment24% of sample (n=657) non-respondersUsed to use slide assessment up to about 2001 but dropped it
75RTC Sex Offender Treatment Program Designed to be delivered over ~7 months13-session intro module thenTwo primary componentsSelf Management – Disclosure; Cognitive Distortions; Emotions Management; Development of Behavioural Progression; Development of Self Management PlanSocial Skills – Communication Skills; Goal Setting; Problem Solving; Empathy; Assertiveness; Relationships
76RTC Sex Offender Treatment Program 4-5 group sessions per week (ideally 4) and one individual therapy sessionEither alternate between Self Management and Social skills sessions (if two different delivery teams) or alternate modulesIn addition milieu therapy – program staff interacting with offenders in unstructured manner on living unitMilieu – allows observation/role modeling in natural environment – . Program staff spend part of each day on the living unit interacting with clients. Occasionally issues associated with treatment are discussed in this context but such interactions also allow staff to be involved in interpersonal interactions among the clients. These interactions give staff an opportunity to intervene and model appropriate problem solving, social interaction skills and conflict resolution in a “real time” context.As well, these interactions also provide staff with an opportunity to observe the behaviour of clients when not in treatment. We believe that clients (particularly psychopathic clients) can succeed in manipulating staff for the two or three hours a day that they are in group. However, they are, from our experience, less able to manipulate well trained staff when their behaviour is monitored 24 hours a day seven days a week. Those clients who are not actively engaged in treatment generally demonstrate inappropriate behaviours on an ongoing basis when not in group.
77Program Delivery Schedule MondayTuesdayWednesdayThursdayFridayAMSelf-Management B GroupPMSelf-Management A&B groupsSocial Skills A&B groupsSocial Skills A GroupSelf-Management A Group/Social Skills B Group2 groups running concurrently
78Program Structure Related to Criminogenic Needs Treatment componentsAntisocial Associates/Negative Social InfluencesSocial Skills/ MilieuAntisocial cognitions/Offence Supportive Attitudes/emotional congruence with Children/Resistance to Rule/SupervisionCognitive Distortions/ Individual Therapy/Social Skills/MilieuAntisocial Personality Pattern/Lifestyle ImpulsivenessCognitive Distortions/Emotions Management/Individual TherapyCriminogenic needs – the central 8, the CN identified by Mann et al. and the needs associated with psychopathy identified by Wong and Hare
79Program Structure Related to Criminogenic Needs Treatment componentsSubstance AbuseEmotions Management/Individual therapyFamily/Marital problems/Lack of emotionally intimate relationships with adultsSocial Skills / MilieuSchool-workLeisure/recreationSocial Skills/Self-Management /Milieu
80Program Structure Related to Criminogenic Needs Treatment componentsSexual PreoccupationEmotions Management /Relationships/ Individual TherapySexual DevianceArousal Management/Emotions management/ IndividualPoor Problem solvingProblem SolvingHostility/dysfunctional emotionsEmotions management / Individual therapy
81Treatment ComponentsWong & Hare (2005) identify as treatment targets for psychopathic offendersDysfunctional attitudes and behaviorsDysfunctional emotions and lack of emotional controlFailure to accept responsibility for their own actionsSubstance abuseLack of work ethic, employable skills and appropriate leisure activitiesAntisocial peers, networks and subcultureNote that these targets correspond to Andrews & Bonta’s bi g 8 risk factors\Each of these targets is addressed in the RTCSOTP components + deviant sexual interests
82Introductory 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 clientsExamples to illustrateKey word here Realistic – what is realistic for the offender – low education, no or few job skills
83Introductory 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”Is this a bad word in NY prisons?What happens when you hear this word?Why?So what do you think when you hear this?
84Introductory Module“I need to retaliate otherwise people will think they can push me around”But isn’t this a thought
85Introductory Module Motivational Issues Psychopathic clients often poorly motivated to changeMotivation to change typically self-focus (get out of prison – “good report”)Work with what you’ve gotFirst sessions focused on motivation/goal setting – finding reason for change
86Introductory Module Process of change How we begin the change process Cost-benefit analysis of changingPossible selves – how do you see yourself after you’ve completed the programRealistic expectations for the futureKey word here Realistic – what is realistic for the offender – low education, no or few job skills
87Change 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
88Old Me New MeOld MeWhat 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 MeBased on these changes what do you think the new me will be like?What goals do you have for yourself in this program?
89Treatment Motivation/Goal Setting Importance of setting goalsSMART principleS = SPECIFICM= MEASURABLEA= ACHIEVABLER= REALISTICT= TIME LIMITEDRequire them to set some goals for the program and monitor progressS = SPECIFIC: a goal is something specific that you want to do, get or achieve. For example, “I will not fight with people” is less specific than “I will learn to stand up for myself without becoming angry.”M= MEASURABLE: how will you know when you have reached your goal? You must be able to see the results of your goal being met. Your goal must be something that can be assessed in a way that you will know whether or not it was achieved. For example, “I will get in better shape” is not measurable. However, “I will lose twenty pounds by this time next year” would be an example of a measurable goal.A= ACHIEVABLE: your goal must be challenging, yet achievable for you.R= REALISTIC: It may take some time to reach your goal but it must be realistic.T= TIME LIMITED: It is crucial to have a timeframe in mind for achieving your goal.
90Introductory Module- Consent Discussion early on in program to start offenders thinking about issues of consentWhat is consentConditions necessary for consenthave to be willing to have sexhave to be able to understand possible consequences of consentinge.g. STDs, pregnancyneed to be soberMust be of age
91Introductory Module- Consent Consent negotiatedReasons for age of consentLegal age vs. age appropriateConsent scenariosNotion that consent is negotiated means that what is going to happen is actually discussed to some extent
92Consent Scenarios1. 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?
93Consent Scenarios3. 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?
94Sex and the MediaDiscussion of the effects of media on sexual attitudes and behaviorfoster skills necessary to exercise responsible and healthy personal choices in using mediapornography = any media that promotes unhealthy beliefs about sexuality, exploits sexuality for commercial purposes, or is sexually degrading.degrading towards both women and menIdea here is that in the real world the offenders will be exposed to sexually oriented media and they need to be prepared to deal with it –Degrading to both women and men in that it exploits male myths and widespread beliefs about male sexuality.
95Sex and the Mediamedia 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 adsRock paper scissors billboard - Toddlers in tiaras
97AB & 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 progressLess than 10 pages too short, more than 30 too long
98AB & Disclosureincludes information regarding times in their lives where they have engaged in criminal behaviouralso periods where they have managed to remain crime free.What was going on when things were going well vs. when things were going poorly
99AB & Disclosure Disclosure – one session per offender 30-45 minutes presentation, break then questions ~ 30 minutesContent of disclosurebrief personal backgroundRelationship historyOffences – but no specific detailWe want to know age and sex of victim – how victim was chosen/groomed etc. but not specific of the sexual assault – those are discussed individually
100AB & Disclosure Questioning – by all group members Clarification Supportive challenging of minimization/denialNot confrontational – Marshall, Marshall, Serran & O’Brien (2011) – therapists who present as warm, empathic, rewarding and directive, but not confrontational most effectiveCite research which indicates that therapists who were rated as confrontational by clients were less effective - clients more likely to withdraw from treatment if therapist rated as confrontational less skilledImportant to remember the goal of the disclosure – 1) to elicit information about offender’s thinking re: his offending; 2) to assist with the development of a behavioural progression; 3) increase accountablity
101AB & DisclosureGoal of these exercises/sessions to increase accountability/openness about offending/sexual devianceNOT looking for the “truth”Official version not the true version of eventsTrauma effects recallReconstructive nature of memoryImportant to remember the goal of the disclosure – 1) to elicit information about offender’s thinking re: his offending; 2) to assist with the development of a behavioural progression; 3) increase accountablityImpossible to determine what the truth is – lots of evidence to suggest that the Official version will contain inaccuracies – trauma affects ability to remember, reconstructive nature of memoryExpect the truth to be somewhere between offical version and offender versionTherefore expectation is a plausible explanation of offence that does not include victim blaming and that acknowledges impact
102AB & DisclosureDO NOT expect offender’s account to match the official versionplausible explanation of offence that does not include victim blaming and that acknowledges impactIs this approach effective in terms of increasing accountability?Important to remember the goal of the disclosure – 1) to elicit information about offender’s thinking re: his offending; 2) to assist with the development of a behavioural progression; 3) increase accountablityImpossible to determine what the truth is – lots of evidence to suggest that the Official version will contain inaccuracies – trauma affects ability to remember, reconstructive nature of memoryExpect the truth to be somewhere between offical version and offender versionTherefore expectation is a plausible explanation of offence that does not include victim blaming and that acknowledges impact
103Columns don’t add to 100% because intermediate group is not displayed e.g. denial of facts pre- other 43% somewhere between full denial and no denailCan see that the number of offenders denying facts decreased from 26% to about 5%Denial of victim harm from almost 50% to about 10%Denial of responsibility from 55% to 15%Notice that some categories Planning, responsibility have relatively high rates post – will come back to this in a moment
104AB & DisclosureCalculate a scale for total denial score in which low scores indicate greater denial
105AB & DisclosureSlight nonsignficant tendency for men discharged from treatment to denyE.g. 36% of discharged deny facts pretreatment compared to 26% of completers
106AB & Disclosure Who gets discharged? attrition table.rtf only disruptive behavior predicts discharge
107130 offenders overallLooking here at the row Static 6+ Denial throughout – 38.9% recidivism – higher than all other groupsNote also that for the moderate risk offenders no denial led to slightly higher recidivism – although non-significant. Get back to that in a minute.N low stat denial through -
108Denial of Impact – full acknowledgement 8.14 2 .017 BSEWalddfpExp BStatic-99R.100.0436.651.0361.09Denial of Impact – full acknowledgement8.142.017Denial Of Impact – some acknowledgement-.87.3077.99.005.420Denial of impact – no acknowledgement-.27.2031.72.190.767Denial of sexual motivation – acknowledgment10.84.004Denial of sexual motivation – some acknowledgement.77.2747.62.0062.128Denial of sexual motivation – no acknowledgment.69.2925.564.0181.993Types of denial – post treatmentNote that the direction of the relationship between reoffending and the two types of denial are opposite. Denial of impact the direction is the more denial the lower recidivism while denial of sexual motivation is more denial greater probability of recidivism.
109Cognitive Distortions Cognitive distortions componentFocus on becoming aware of distorted thinkingBoth generally criminal and associated with sexual offendingChallenging cognitive distortions without being confrontational.Use the group processAddress common distortions related to both general criminal behavior and sexual criminal behaviour – use the group process to assist with thisEncourage group members to point out distortions in each others thinking
110Cognitive Distortions What information has the client previously provided which is contradictory to the distortion?What is the evidence for the thought?Remain neutral.
111Cognitive Distortions Use of ACT model to challenge distortionsAwareness of distorted thinking.Choose to think rationally (what is true, what is not).Take action - Replace with appropriate thoughts.
112Cognitive Distortions Important notion re: cognitive distortions is the idea of excuse makingMann & Maruna (2006; Mann & Ware, 2012) – normal human tendency toward excuse makingexcuse 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. 156It’s not my fault because….
113Cognitive 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. 158Mann & Maruna argue that the labelling of distortions as something negative that have to be challenged and changed in treatment is akin to the fundamental attitubution errorFundament attribution error: tendency to over-value dispositional or personality-based explanations for the observed behaviors of others while under-valuing situational explanations for those behaviors. The fundamental attribution error is most visible when people explain the behavior of others. It does not explain interpretations of one's own behavior—where situational factors are often taken into consideration. This discrepancy is called the actor–observer bias.
114Cognitive 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
115Cognitive 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. DistortionsSo offenders aren’t that different from everyone else
116Cognitive 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.
117Cognitive 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.
118Cognitive Distortions Hanson & Morton-Bourgon (2004) no relationship between denial of sex crime or minimizing responsibility and recidivismHowever more recent research has shown that there is a relationship between denial and recidivism for some offenders
119Cognitive Distortions Also note that there is no evidence to support the notion that cognitive distortions (as distinct from offence supportive attitudes) predict recidivism
120So going back to this slide – denial of responsibility and denial of planning can be seen as excuse-making vs. offence related attitudesNotice that some categories Planning, responsibility have relatively high rates post – will come back to this in a moment
121Denial of Impact – full acknowledgement 8.14 2 .017 BSEWalddfpExp BStatic-99R.100.0436.651.0361.09Denial of Impact – full acknowledgement8.142.017Denial Of Impact – some acknowledgement-.87.3077.99.005.420Denial of impact – no acknowledgement-.27.2031.72.190.767Denial of sexual motivation – acknowledgment10.84.004Denial of sexual motivation – some acknowledgement.77.2747.62.0062.128Denial of sexual motivation – no acknowledgment.69.2925.564.0181.993This slide here denial of impact = “it wasn’t so bad” – post hoc excuse making vs. offence supportiveDenial of sexual motivation - Child molesters – I was just trying to be her friend
122Cognitive 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.Important to remember the goal of the disclosure – 1) to elicit information about offender’s thinking re: his offending; 2) to assist with the development of a behavioural progression; 3) increase accountablityImpossible to determine what the truth is – lots of evidence to suggest that the Official version will contain inaccuracies – trauma affects ability to remember, reconstructive nature of memoryExpect the truth to be somewhere between offical version and offender versionTherefore expectation is a plausible explanation of offence that does not include victim blaming and that acknowledges impact
123Cognitive Distortions Cognitive Distortions thatImpede EmpathyDo not have victim empathy/empathy training componentMann et al. (2011) – victim empathy not associated with recidivismMarshall et al. – empathy deficits are victim specific rather then generalizedWe don’t do letters taking responsibility – don’t do roleplays etc
124Cognitive Distortions Instead discuss cognitive distortions that impede empathyView videos to illustrate victim impactDiscuss specific distortions used to shut down empathyDistorted thinking allows offenders to shut off empathy for victim at time of offence
125Attitudes Discussion of helpful vs. harmful attitudes How do we know?How do positive attitudes affect our behaviour?
126AttitudesMr. 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."
127Attitudes "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?"Questions to ask to generate discussion
128Attitudes Identify the negative attitudes expressed which positive attitudes could be substitutedHow 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
129Emotions Management Component Addresses coping with difficult emotional states – loneliness, jealousy, depression etc.Cognitive strategies – self-talk, challenging distortionsBehavioural strategies – relaxationAcceptance of negative emotions
130Emotions ManagementAwareness of emotions – how do we know what we are feeling?Bodily signalsSelf talkSelf monitoring homeworkDiscussion of various “high risk” emotionsSadness, anxiety, anger, hostility, loneliness, shame/guilt, self pityHow do these emptions differ from each other in terms of the cogntiion, physical sensations which accompany them
131Emotions ManagementAlso discuss positive emotions which may place someone at riskDistorted cognitions which accompany feelings of happiness related to success/accomplishmentLink these emotions to behavioural progressione.g. just got a raise at work, need to go out and celebrateBaseball team won the tournament
132Emotions Management Anger Discussion of role of anger It is a “normal” emotioncan be helpfulCognitive and physical signals related to angerAddressing cognitive distortions that lead to anger
133Anger Emotions Management 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.
135Emotions Management When 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.
136Emotions Management Strategies for managing emotions Assertion vs. aggressionSelf-talkRelaxation/mediation/mindfulnessEffective communication
137Emotions Management Sexual arousal Discussion the notion that sexual arousal is a feelingCan be managed like other feelingDon’t need to act on itSame strategies applyDiscussion of arousal management strategiesIn group keep conversation general – not specific discussion of fantasy content
138Arousal Management Individual therapy sessions Every offender discussion of fantasy and how it relates to offencesSexual fantasy monitoringdiscussion 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)
139Arousal Management Fantasy/arousal modification Covert sensitization develop fantasy scripts – deviant and appropriateDevelop strategies for controlling arousalIn lab – monitor arousal while reciting scriptUse strategies to diminish arousal – then use appropriate fantasy to generate arousalIf not successful refer to psychiatristStrategies – preference to be focusing on victim harm – learned that in the cog distortions componentSome offenders doesn’t work harm/embaressment to self
140Behavioural Progression Different ways of doing BP – e.g. Yates Kingston & Ward (2010)Prefer simpleSeries of thoughts, feelings and behaviours which culminate in sexual offenceClients to identify 7-10 such sequencesIf multiple offences chose “typical” offence
144Social Skills Component Majority of high risk/needs clients lack in basic social skillsRisk factorsAntisocial peers, networks and subcultureLoneliness, lack of prosocial relationships, poor job prospects, intimacyFocusing on enhancing skills to develop/maintain prosocial relationshipsHeavily focused on skill-buildingLack of social skills related to risk factor of antisocial peers etc.Use of role-plays in most sessions
145Social Skills Component Values identificationServes as basis for much of discussion in coming componentsWhat 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
146Social Skills Component Communication Skills – oriented toward developing appropriate relationshipsReplacing aggressive communication (which has likely been reinforcing for the client in the past) with listening skills and active listeningEmphasis on costs and benefits of aggressive communication (decision matrix)Notice that as we go through the various components the self-management component and the social skills component complement each other in terms of the content and skills
147Social Skills Component Problem solving/AssertivenessRecognize 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 oneHelp them to keep jobs
148Social 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 jealousyNegotiating consentHow to chose a partnerAvoiding impersonal sex
149Disclosing criminal history to partner Relationship SkillsDisclosing criminal history to partnerRole playPrivacy circle discussionDescribes the development of relationshipsFrom stranger to intimaterelationships develop3-date rule
150Relationship Skills Purple - You This is the center of the circles and you are the only person in this circle. This means that you are the most important person in your world and you are the center of your circles. Where people are placed in the circles depends on your relationship with the person.Blue - IntimatesThis is the second circle and is the circle that is closest to you. It has people who are close to you. This circle usually has your mother and father and possibly a girlfriend or boyfriend in it.Green - FriendsThis circle includes people that you have less physical contact with than people in your blue circle. You may hug these people but only on special occasions and the hug only lasts a short time. This circle may include family members and close friends that you really like spending time with.Yellow - AcquaintancesThis circle includes people that you shake hands with. This may include acquaintances and other people you know. These are people that you do not have an emotional bond with and you have very little physical contact with them.ORANGE – casual acquaintanceThis circle includes the people where you know their name but that may be all that you know about them. You do not know these people very much. You do not have any physical contact or emotional bond with these people. This may include casual acquaintances, neighbours, and children. YOU SHOULD ALWAYS PUT CHILDREN YOU KNOW IN THIS CIRCLE.Red- STRANGERThis circle holds two different types of people:Strangers: these are people that you do not know and you should not have any type of contact with them. You do not touch them or speak to them.The community helper: these are people who have a job where they are there to help you. You do not know these people but you talk to them because of their job (for example: police, nurses, doctors, dentists, parole officers, social workers). If these people touch you it is only to do their job. You should not touch these people.
151Relationship SkillsIdeal Partner – asked to describe in terms of: Appearance, Attitudes, Education, Career, Personality traits, interests/hobbies, Religion, Cultural background,Rank importance - 1 to 8Is their ideal partner consistent with the values they identified earlier?Don’t go from first meeting to moving in in a day "How does your "Ideal Partner" compare to what you want out of a relationship?" "How does your "Ideal Partner" compare with the partners you have chosen in the past?“Typically looking for rather pro-social things in relationships – nobody says I'm looking for a drug addicted prostitute with missing teethMost of the time real partners will not match up to ideal partner - how realistic are their expectations
152Relationship SkillsWhat do they bring to the relationship – what can they offerOften 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 compromiseAgain – how realistic are their expectationsFacilitators will lead the discussion by stating that now that many of you have realized that your goals may not be met, what do you think you can do to change this?Responses may include: Change your goals Lower your expectations Re-evaluate the things that are important in a partner6. Facilitators can point out that clients may need to compromise in order to attain their goals: "Looking at your "ideal partner", what are you prepared to compromise?" "Can you live comfortably with these compromises?" "If you are not happy with these compromises, then this could cause problems in the relationship in the future."
153Relationship Skills Maintaining Relationships Relationships require workFace strain from change – children, job lossOther relationships – in-lawsShow respectBe honest and truthfulDo little things to show you careTreat your partner as an equalTake equal responsibilityMake time (for family, for partner, for yourself)Be open to changeMaintain individuality/respect individuality of partnerAgain – how realistic are their expectationsFacilitators will lead the discussion by stating that now that many of you have realized that your goals may not be met, what do you think you can do to change this?Responses may include: Change your goals Lower your expectations Re-evaluate the things that are important in a partner6. Facilitators can point out that clients may need to compromise in order to attain their goals: "Looking at your "ideal partner", what are you prepared to compromise?" "Can you live comfortably with these compromises?" "If you are not happy with these compromises, then this could cause problems in the relationship in the future."
154Relationship Skills Coping with loneliness, rejection and jealousy Being alone vs. lonelinessWhat does it mean to “be alone”Advantages of not having a partnerRejection – what does it mean when someone rejects you?Possible reasons for rejectionWays to copeComplements emotions management componentRejection –Reactions for being rejected – feeling hurt, feeling angry etc.Why might someone reject you – mannerisims, behaviours (drinking, drug use, aggression)personal issues of their ownpersonalizing, overgeneralizinggo back to the cog. Distortions component – how to deal with this sort of thinking
155Relationship Skills Coping with loneliness, rejection and jealousy Jealousy – what is jealousy and why do we feel itWhen you don't feel good about yourselfWhen you are dependent on your partner for your happinessWhen you don't enjoy spending time aloneWhen you lack social skillsWhen your expectations aren't being metWhen you've made the wrong partner choiceLacking social skills – communication, assertiveness etc.
156Relationship Skills Coping with jealousy Try to determine if the jealousy is based on fact or fearCommunicate your feelings to your partner in the very beginningDon't allow negative self-talk to get out of handNegotiate with your partner ways to avoid situations that perpetuate the jealousySeek counsellingThese task obviously require advance social skills – communication, assertiveness etc.
158Self Management Puts everything from program together Remind themselves of goals/reasons for changeIdentify risk factors and main coping strategiesRelapse CuesAppropriate use of leisure timeMain sources of supportPresent/discuss in groupRisk factorsPeople, places, things
160Individual therapy component Address issues unique to the individual not addressed in groupFollow-up on issues which come up in groupAssist with homeworkArousal work
161Individual therapy component Substance AbuseCSC has comprehensive substance abuse programming therefore do not target directly in SOTPDiscuss role substance abuse plans in offence progressionImportance of avoiding substance abuse in risk management/prosocial lifestyleDon’t mix substance use and sex
162Individual Therapy Importance of rapport. Understanding that treatment with such clients is a long term undertaking.Prepare offender for dealing with the lapses that WILL occurDrug useFightingAngry outbursts
163Individual 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 thingBehavioral contracts .What is the client really after-Is it a reasonable request?Sometimes what some staff see as manipulative/demanding is actually a reasonable request.e.g. johnson and BMR based on other offender’s say so
164Program Referrals RTC WSBC Maintenance Bath SOP The other Possibility is that after completing the RTC they simply are releasedBath SOP
165Treatment OutcomeNote: 6+ group average PCL-R score about 25, 22% over 30
167Treatment OutcomeSexual Recidivism for men with PCL-R scores over 25 AND Static-99 over 5n=70 follow-up 4.5 years15.7% new sexual convictionpsychometric table.docx
168% Any Violent recidivism Treatment Outcome% SexualRecidivism% Any Violent recidivismRTC only (n=152)11.824.3RTC + Mod (n=24)8.312.5RTC+ Mod + Maintenance (n=11)Over 7-year follow-upN’s small but data suggests that adding the moderate programming and maintenance decreases in recidivismModerate program typically not another full program, but targetted toward addressing outstanding needs
170Community 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.
171Community 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.
172Community 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.
173Specific Challenges with High Risk Offenders Manipulative behaviorsNeed 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.
174Specific 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.
175Community 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.
176General GuidelinesFor 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.
177General GuidelinesIf 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.
178General GuidelinesHaving 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 fileIndividual therapy and/or group treatment are available.
179Sex Offender Maintenance Treatment 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.
180Specific 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.
181Specific Challenges with High Risk Offenders Substance AbuseDecision 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.
182Legal 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) LegislationLong Term Offender (LTSO) Legislation.
183Dangerous Offender Legislation Criteria for DO designation:Demonstrated failure to control sexual impulsesThere is a likelihood of causing injury, pain, or other evil to other persons in the futureBecause of the brutal nature of the offence.Typically reserved for offenders with extensive criminal histories.Must be convicted of a serious personal injury offense.
184Dangerous 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.
185LTSO 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 moreThe court may impose a maximum of 10 years of supervision.
186LTSO 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.
187LTSO 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.
188LTSO 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.
189LTSO 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 policeFrequent team discussions regarding these cases.
190LTSO Offenders In Ontario as of 2011 there were 178 men with LTSO 81 were in the community.18 additional were suspendedMost of these are released to one of the CCCs.
191Community Treatment Outcome Followed 25 sex offenders released to Keele CCC in 200711/25 LTSO19 were involved in treatmentOf 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
192Community Treatment Outcome None of these men were convicted of a new sexual offence in the follow-up periodTwo were convicted for violent non-sexual offencesOne of these received community treatment
193LTSO OffendersThese 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.