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Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for Clinicians Jan Looman, Ph.D., C.Psych. Kingston, Ontario

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Presentation on theme: "Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for Clinicians Jan Looman, Ph.D., C.Psych. Kingston, Ontario"— Presentation transcript:

1 Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for Clinicians Jan Looman, Ph.D., C.Psych. Kingston, Ontario 1

2 Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for Clinicians  Note: The views expressed here are the views of the author and do not reflect the views of the Correctional Service of Canada 2

3 Outline 1.Models of Treatment - RNR vs. GLM 2.Describe triage process for sex offenders in Ontario/Canada 3.What do I mean by “high risk/needs”? 4.Describe treatment process for High Risk/Needs Sex Offenders 5.Link to community treatment – continuity of care 3

4 Models of Treatment  What really is RNR?  RNR vs. GLM  Is the Good Lives model different? 4

5 Models of Treatment  RNR model is not a theory of intervention in itself – it represents principles of effective correctional intervention (Andrews & Bonta, 2010)  derived from Andrews and Bonta’s general personality and cognitive social learning (GPCSL; Andrews & Bonta, 2010) theory of criminal behavior. 5

6 Models of Treatment  GPCSL posits that crime results when the personal, interpersonal, and community supports for behavior are favorable to crime  Strong influences - antisocial attitudes, antisocial associates, a history of offending, antisocial personality traits.  Weaker influences - familial difficulties, poor adjustment to work and school. 6

7 Models of Treatment RNR Principles – guide us in designing intervention within the GPCSL theory  The Risk Principle - that higher levels of intervention should be reserved for higher risk cases - low risk offenders should receive no, or very little intervention.  Risk is to be determined through validated actuarial assessment of static and dynamic risk 7

8 Models of Treatment  The Need Principle - interventions should target criminogenic needs (dynamic risk factors).  Central Eight risk/need factors (Andrews & Bonta, 2010): –antisocial associates, –antisocial cognitions, –antisocial personality pattern, –history of antisocial behavior, –substance abuse, –family–marital, –school–work, –leisure–recreation. 8

9 Models of Treatment  Sex offender specific criminogenic needs identified by Mann, Hanson & Thornton (2010) –Sexual preoccupation –Sexual deviance – esp. deviant arousal to children; multiple paraphilias –Offense-supportive attitudes –Emotional congruence with children 9

10 Models of Treatment  Sex offender specific criminogenic needs (con’t) –Lack of emotionally intimate relationships with adults –Lifestyle impulsiveness –Poor problem solving –Resistance to rules/supervision –Hostility –Negative social influences 10

11 Models of Treatment  Other factors identified as “Promising” criminogenic needs: –Hostility toward women –Machiavellianism –Lack of concern for others –Dysfunctional coping –Sexualized coping –Externalized coping 11

12 Models of Treatment Non –Criminogenic Needs Hanson & Morton- Bourgon (2005)  Force/violence in sex offending  Neglect or abuse during childhood  Sexual abuse during childhood  Loneliness*  Low self-esteem  Lack of victim empathy  Denial of sexual crime *  Low motivation for treatment at intake  Poor progress in treatment (post) 12

13 Models of Treatment  Within the Need Principle non-criminogenic needs not relevant targets for intervention  A caveat to this: dealing with a noncriminogenic need may be an important strategy in the context of addressing a specific responsivity factor.  Treatment providers must build on strengths and remove barriers to effective participation enhancing responsivity (Andrews, Bonta & Wormith (2011) 13

14 Models of Treatment The Responsivity Principle 1.general - the most effective interventions tend to be those based on cognitive, behavioral, and social learning theories 1.the relationship principle (Andrews, 1980) (establishing a warm, respectful and collaborative working alliance with the client) and, 2.the structuring principle (influence the direction of change towards the prosocial through appropriate modeling, reinforcement, problem-solving, etc.) 14

15 Models of Treatment The Responsivity Principle 2.specific responsivity - the treatment offered is matched not only to criminogenic need but to those attributes and circumstances of cases that render them likely to profit from that treatment 15

16 Models of Treatment Responsivity Factors (Looman, Dickie & Abracen, 2005; Olver, Stockdale & Wormith, 2011)  psychopathy  Low motivation/ denial/minimization  low intellectual functioning/lack of education  hostile interpersonal style/disruptive  Mental health difficulties  personality profile 16

17 Models of Treatment Summary RNR  Treatment directed toward higher risk clients  Addresses known criminogenic needs  Cognitive behavioural/social learning approaches  Emphasis on effective therapist characteristics and role modeling delivered in a manner appropriate for the client group 17

18 Evidence for RNR   Dowden and Andrews (1999) - meta-analysis of 25 studies of treatment for female offenders  effect sizes larger when criminogenic needs were targeted.   treatment services which adhered to all of the RNR principles found to be related to the greatest reductions in recidivism, while treatment rated as inappropriate had the weakest effects.   targeting vague personal/emotional targets, family interventions not addressing criminogenic needs, and other non-criminogenic personal treatment targets were associated with no reduction in recidivism. 18

19 Evidence for RNR   Dowden and Andrews (2000) - meta-analysis 35 studies of treatments for violent offenders   criminal sanctions alone  no effect on recidivism   any human service delivery  significant positive effect.   programs which adhered to RNR principles were more effective than those which did not   Programs targeting criminogenic needs associated with a moderate effect size - those which did not produced no significant reduction in recidivism. 19

20 Evidence for RNR   Dowden and Andrews (2000) (con’t)   Programs that adhered to all three RNR principles produced the largest effect sizes.   correlation between effect size and number of criminogenic needs targeted was.69 (p <.001)   correlation between effect size and number of non-criminogenic needs was -.30 (p <.05). 20

21 Evidence for RNR   Hanson, et al. (2009) - 23 studies of sexual offender treatment   adherence to the RNR principles  greater reductions in recidivism   effect was linearly related to the number of RNR principles adhered to.   programs which adhered to none of the principles  a negative treatment effect. 21

22 Evidence for RNR   Dowden, Antonowitz and Andrews (2003) - meta- analysis of 24 studies of treatment programs which employed an RP approach in the delivery of treatment.- (7 addressed sex off).   moderate overall effect size for RP programs   Coded presence of various aspects of the RP approach (i.e., offence chain, relapse rehearsal, advanced relapse rehearsal, identification of high risk situations, training significant others, Booster sessions, coping with failure situations) 22

23 Evidence for RNR   Dowden et al (2003)   Overall, the greater the number of RP components employed in treatment, the stronger the treatment effect (r =.38, p <.01).   found that RP programs which adhered to all three RNR principles had the greatest impact, while those that adhered to none of the principles had no impact on recidivism. 23

24 Evidence for RNR Summary  Treatment approaches which adhere to RNR principles effective in reducing recidivism for violent offending, female offenders, sexual offenders  RP approaches which adhere to RNR principles also effective  Approaches which focus on noncriminogenic needs (for SOs internalizing psychological problems denial, low victim empathy, and social skills deficits) non-effective or even harmful 24

25 Models of Treatment Good Lives Model 25

26 Good Lives Model Assumptions about Human Nature  Assumes all human being are practical decision-makers and have similar aspirations and needs  one of the primary responsibilities of parents/teachers to equip people with the skills/tools to make their own way in the world 26

27 Good Lives Model Assumptions about Human Nature (con’t)  People formulate plans and intentionally modify themselves and their environment in order to achieve goals  In order for people to function effectively their basic needs must be met 27

28 Good 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 reproduce  People derive a sense of who they are and what matters from what they do (Practical identity)  Therefore in rehab need to provide offenders with an opportunity to acquire a more adaptive practical identity 28

29 GLM on RNR Criticize RNR approaches  focus on risk reduction/management unlikely to motivate offenders – need to have approach goals  pay attention to offender as a whole - RNR sees offender as “disembodied bearer of risk”  Lack of focus on non-criminogenic needs – therapeutic relationship  RNR approaches “one-size fits-all” 29

30 What Does the GLM Say Nine* 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); 30

31 GLM 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; and  9. creativity. 31

32 GLM & Offending  Criminogenic needs = internal or external obstacles that frustrate and block the acquisition of primary human goods  Individual lacks the ability to obtain the good in a prosocial manner and is unable to think about his life in a reflective manner  i.e. criminogenic needs =deficiency in agency and conditions that that support agency 32

33 GLM & Offending  4 major difficulties with offender’s life plans that lead to offending 1.Means he uses to secure goods a)Inappropriate strategies  Violation of norms 2.Lack of scope – important good missing e.g., lack if connectedness  feelings of loneliness/inadequacy 33

34 GLM & Offending  4 major difficulties with offender’s life plans that lead to offending (con’t) 3.Conflict among goods sought – e.g. attempt to pursue good of autonomy leads to relationship issues 4.Lack of capability – knowledge/skills deficits 34

35 GLM & Offending  Two routes to the onset of offending 1.Direct – offending is the primary focus – e.g., offender may lack the relevant competencies and understanding to obtain the good of intimacy with an adult – offending = striving for fundamental goods – intentionally seeks goods through criminal activity. 2.Indirect – pursuit of a good increases the pressure to re-offend – e.g. conflict between good of relatedness and autonomy leads to break-up of relationship  loneliness/distress  alcohol use  offending 35

36 GLM & Offending  Offenders search for primary goods in their environments under the guidance and constraint of their practical identity –Act in ways that they think will satisfy them –Sex offending arises because people make faulty judgements –Lack of forethought or knowledge concerning relevant facts 36

37 GLM & Intervention  Should be a direct relationship between goods promotion and risk management  Rehabilitation = holistic reconstruction of the self  new practical identity  Focus on promotion of goods is likely to automatically eliminate or modify risk factors  Attitude of therapist – offender viewed as someone attempting to live a meaningful, worthwhile life in the best way he can in the specific circumstances confronting him 37

38 GLM & Intervention  Tailoring of therapy to match the individual client’s life plan and their risk factors  Therapeutic task shaped to suit the person in question  Focus on approach goals rather than avoidance of risk factors 38

39 GLM & Intervention Assumptions/Considerations (Laws & Ward, 2011)  Offenders lack many of the essential skill/capabilities to achieve a fulfilling life  Criminal behaviour = attempt to achieve desired goods but the skills/abilities absent – alternatively:  Criminal behaviour arises from an attempt to relieve a sense of incompetence, conflict, or dissatisfaction that arises from not achieving valued human goods. 39

40 GLM & Intervention Assumptions/Considerations (con’t)  Laws & Ward (2011)  The absence of certain goods more strongly related to offending**: 1.Self-efficacy/sense of agency 2.Inner peace 3.Personal dignity/social esteem 4.Generative roles and relationships (work, leisure) 5.Social relatedness (associates ). 40

41 GLM & Intervention Assumptions/Considerations (con’t)  Risk of offending reduced by assisting individuals to develop the skills/abilities to achieve the full range of human goods  Intervention = activity that adds to an individual’s repertoire of personal functioning rather than simply removing a problem or managing a problem 41

42 Evidence for the GLM  Laws & Ward (2011) indicate (p. 202) that the GLM has empirical support – however they fail to offer any citations  The area of positive psychology generally is empirically based however this cannot be taken as evidence that such approaches are effective with offenders  E.g. Deci & Ryan (2000) - self-determination is positively correlated with personal well- being 42

43 Evidence 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 needs  E.g. White, Ward & Collie, 2007 – Mr. C. gang member with long criminal history of violence including sexual violence –Noted that he had engaged in RNR based interventions on previous sentences –Remained in pre-contemplation and rigid antisocial attitudes, continued drug use 43

44 Evidence for GLM  Mr. C. (con’t)  Treatment according to GLM  Outcome – 14 months following release  Disclosed two violent incidents  “The first involved a retaliatory action after being pushed to the ground at a party. … The second relapse occurred in response to his partner being insulted and offended. Mr. C’s reaction included “smashing” the victim and entering an emotional state synonymous with the abstinence violation effect 44

45 Evidence for the GLM Specific to Offenders?  Harkins, Flak, Beech & Woodhams (2012) –76 men who participated in GLM based community SO treatment –701 who participated in an RP oriented treatment 45

46 Evidence for GLM Harkins et al.(2012) (con’t) 1.pre-post treatment psychometric assessment – measures which previous research demonstrated associated with recidivism 2.Attrition rates 3.Facilitators perception of the program and offender’s motivation 4.Offender’s perception of the program 46

47 Evidence for GLM Harkins et al.(2012) (con’t)  Attrition rates did not differ significantly  No difference in rates of change on psychometric measures  Facilitators liked the GLM-based module  63.7% did not think it would be appropriate for high-risk/unmotivated clients 47

48 Evidence for GLM  Harkins et al.(2012) (con’t)  Clients rating of improved understanding of their offending - 80% of RP group compared to 46% GLM  better understanding of the positive aspects of themselves 61% for GLM compared to 20% for RP 48

49 Evidence for GLM  Harkins et al.(2012) (con’t)  Rating re: changing thoughts and attitudes in a way that they were better able to manage themselves or their reoffending 80% for RP, vs. 27% for the GLM module  thoughts and attitudes about themselves or the future were more positive - 47% for GLM vs. 20% for the RP module. 49

50 Evidence for GLM  Harkins et al.(2012) (con’t)  Summary  GLM module led to offenders who feel better about themselves and their future, however did not improve their awareness of risk factors and self-management strategies  Opposite was true for RP/RNR based program  no differences overall in terms of attrition or change on risk factors 50

51 GLM vs. RNR  Does GLM say anything that RNR does not?  GLM: Criminal behaviour arises from an attempt to relieve a sense of incompetence, conflict, or dissatisfaction that arises from not achieving valued human goods  RNR approach: crime results when the personal, interpersonal, and community supports for behavior are favorable to crime 51

52 GLM vs. RNR  RNR focuses on the Central Eight - addressing such needs as lack of education and employment and lack of supportive, rewarding, and prosocial familial and marital relationships  GLM identifies 9 “goods” with a great deal of overlap with the Central eight 52

53 GLM vs. RNR GLM goods 1.Knowledge 2.Excellence in Play and Work 3.Autonomy 4.Inner peace 5.Relatedness/ Community 6.Spirituality 7.Happiness/Creativity RNR Central Eight 1.Schooling/Employment 2.Employment/leisure 3.Employment/cognitions/ attitudes 4.Antisocial cognitions; antisocial personality pattern 5.Associations/Family marital 6.Antisocial attitudes 7.Leisure/work/family/ associates 53

54 GLM vs. RNR  Both models discuss the importance of acquiring skills  Ward et al. claim that the GLM addresses criminogenic needs by building strengths and being positively oriented  Andrews & Bonta(2010) discuss the importance of prosocial skills building and role- modeling by treatment providers 54

55 GLM vs. RNR  Wormith, Gendreau & Bonta (2012) - some of the professed shortcomings of RNR and alleged differences between RNR and GLM are illusory. –E.g., the difference between addressing deficits and building strengths. From a practical field- level perspective, the difference is mostly semantic 55

56 GLM vs. RNR  The need to use approach goals and positive language is a contribution – field too often focused on negative  No evidence this leads to greater benefit from treatment 56

57 RTC Sex Offender Program 1.Triage Process 2.What do I mean by High Risk/Needs 3.RTC program 57

58 Triage Process in Ontario  RTCSOTP in operation from 1972 to 2011  Only institutional sex offender program in Ontario until 1989  WSBC initiated at that time  1992 Sex Offender Assessment Team established at the Millhaven Assessment Unit 58

59 MAU Assessment  MAU Sex Offender Assessment team assesses all sex offenders entering the Federal prison system in Ontario  In Canada sentence 2+ years served Federally  Assessment addresses level of risk (actuarial) and treatment needs 59

60 MAU Assessment (con’t)  Initially used PCL-R, SORAG, LSI-R, RRASOR and case history  added Static-99/STABLE when available  Dropped PCL-R/SORAG in

61 MAU Assessment (con’t)  developed first National Standards for sex offender treatment  established Low, Moderate and High Intensity designations 61

62 Intensity Levels  With Standards we (i.e., regional sex offender program directors) adopted these levels of intensity  RTCSOTP=high  WSBC=moderate  Bath (est. ~ 1992) low-moderate  late 1995 RTCSOTP focus on high risk, high treatment needs offenders 62

63 Intensity Levels  Risk/Needs defined according to RNR principles:  Risk assessed actuarially  Need defined in terms of established criminogenic needs (intimacy deficits, attitudes, deviant arousal, problem solving, social competence, etc.) 63

64 MAU Moderate WSBC HISOP RTC** **Low Pittsburgh Low-Mod Bath 64

65 RTC Sexual Offender Treatment Program 65

66 RTCSOTP  Description of the Clientele  Program Components  Outcome data 66

67 Actuarial Risk 67

68 Changes over Time 68

69 Program Differences Note: a Hi intensity differs from Moderate b Hi intensity same as moderate but different from other groups b Hi intensity same as moderate but different from other groups HiModLo-ModLo LSI-R b Static-99 a STABLE a

70 Diagnosis  Finally, use DSM diagnoses to determine the presence of increased responsivity needs  looked at 48 consecutive admissions to the SOTP (in 2005)  37 (77.1%) meet criteria for a personality disorder  15/37 (40.5%) have personality orders described as “severe” by the diagnostician (e.g., BPD, Narcissistic, psychopathy) 70

71 Diagnosis (con’t)  Behaviours resulting from these PD’s lead to management difficulties in their parent institution, including long-term segregation (15, or 31%)  16/48 (31.3%) suffer from mood disorder (Depression, Bipolar Disorder)  10 (28%) suffer from psychosis 71

72 Diagnosis (con’t)  22 (45.9%) met the criteria for a paraphilia, most often sexual sadism or pedophilia  Nine of these 22 (41%) also meet criteria for severe personality disorder – typically psychopathy or borderline 72

73 Deviant Arousal  Every admission to our program assessed via PPG  Men with child victim audio child sexual violence assessment (Quinsey & Chaplin, 1988)  Men with adult victims adult sexual violence assessment (Quinsey, Chaplin & Varney, 1981) 73

74 Deviant Arousal  40% of adult rapists deviance on adult sexual violence assessment  92% of child molesters deviant on child sexual violence assessment  24% of sample (n=657) non-responders 74

75 RTC Sex Offender Treatment Program  Designed to be delivered over ~7 months  13-session intro module then  Two primary components 1.Self Management – Disclosure; Cognitive Distortions; Emotions Management; Development of Behavioural Progression; Development of Self Management Plan 2.Social Skills – Communication Skills; Goal Setting; Problem Solving; Empathy; Assertiveness; Relationships 75

76 RTC Sex Offender Treatment Program  4-5 group sessions per week (ideally 4) and one individual therapy session  Either alternate between Self Management and Social skills sessions (if two different delivery teams) or alternate modules  In addition milieu therapy – program staff interacting with offenders in unstructured manner on living unit 76

77 Program Delivery Schedule MondayTuesdayWednesdayThursdayFriday AM Self- Management B Group PM Self- Management A&B groups Social Skills A&B groups Social Skills A Group Self-Management A Group/Social Skills B Group 77

78 Program Structure Related to Criminogenic Needs Criminogenic NeedTreatment components Antisocial Associates/Negative Social Influences Social Skills/ Milieu Antisocial cognitions/Offence Supportive Attitudes/emotional congruence with Children /Resistance to Rule/Supervision Cognitive Distortions/ Individual Therapy/Social Skills/Milieu Antisocial Personality Pattern /Lifestyle Impulsiveness Cognitive Distortions/ Emotions Management /Individual Therapy 78

79 Program Structure Related to Criminogenic Needs Criminogenic NeedTreatment components Substance Abuse Emotions Management /Individual therapy Family/Marital problems/Lack of emotionally intimate relationships with adults Social Skills / Milieu School-work Leisure/recreationSocial Skills/ Self-Management /Milieu 79

80 Program Structure Related to Criminogenic Needs Criminogenic NeedTreatment components Sexual Preoccupation Emotions Management /Relationships/ Individual Therapy Sexual Deviance Arousal Management/ Emotions management/ Individual Poor Problem solvingProblem Solving Hostility/dysfunctional emotions Emotions management / Individual therapy 80

81 Treatment Components  Wong & Hare (2005) identify as treatment targets for psychopathic offenders 1.Dysfunctional attitudes and behaviors 2.Dysfunctional emotions and lack of emotional control 3.Failure to accept responsibility for their own actions 4.Substance abuse 5.Lack of work ethic, employable skills and appropriate leisure activities 6.Antisocial peers, networks and subculture 81

82 Introductory Module  Introduces offender to the program  Group rules (arrived at through group discussion)  Treatment concepts/Jargon (CBT, Offence Chain etc.)  CBT – the idea that thoughts and behavior are related new to clients –Examples to illustrate 82

83 Introductory Module  “goof”  need to fight  “I need to retaliate otherwise people will think they can push me around”  “I don’t think – I just react” 83

84 Introductory Module  “I need to retaliate otherwise people will think they can push me around” 84

85 Introductory Module  Motivational Issues  Psychopathic clients often poorly motivated to change  Motivation to change typically self-focus (get out of prison – “good report”)  Work with what you’ve got  First sessions focused on motivation/goal setting – finding reason for change 85

86 Introductory Module  Process of change –How we begin the change process –Cost-benefit analysis of changing –Possible selves – how do you see yourself after you’ve completed the program –Realistic expectations for the future 86

87 Change Process  Have offender identify a role model   “Can you name anybody from your life who is not a criminal that you might use as a role model?”   Old me /New me homework 87

88 Old Me New Me   Old Me   What would you like to change about your personality and how you act?   What strengths do you have that will help you to make these changes?   New Me   Based on these changes what do you think the new me will be like?   What goals do you have for yourself in this program? 88

89 Treatment Motivation/Goal Setting  Importance of setting goals  SMART principle –S = SPECIFIC –M= MEASURABLE –A= ACHIEVABLE –R= REALISTIC –T= TIME LIMITED  Require them to set some goals for the program and monitor progress 89

90 Introductory Module- Consent  Discussion early on in program to start offenders thinking about issues of consent –What is consent –Conditions necessary for consent –have to be willing to have sex –have to be able to understand possible consequences of consenting –e.g. STDs, pregnancy –need to be sober –Must be of age 90

91 Introductory Module- Consent  Consent negotiated  Reasons for age of consent  Legal age vs. age appropriate  Consent scenarios 91

92 Consent Scenarios  1. You are in a bar and you are getting along well with a woman who seems quite interested in you. However, you realize that she looks quite young - although it is certainly possible that she is 19 years old. What do you do?  2. Your 13 year old step-daughter comes into the room in a see-through night gown and cuddles up to you on the couch. No one else is home. Is she indicating that she is sexually interested in you? 92

93 Consent Scenarios  3. You have met the same woman at the bar you like to go to several times before. Tonight things have become very friendly and you think that she really likes you. At closing time you ask her back to your place for a drink. She accepts. What would you do from here?  4. Same situation as above except that you have been “fooling around” (i.e., kissing and caressing each other) while at the bar. At closing you ask her if she would like to “continue this at your place” - she accepts. Do you have consent? Consent for what? 93

94 Sex and the Media  Discussion of the effects of media on sexual attitudes and behavior  foster skills necessary to exercise responsible and healthy personal choices in using media  pornography = any media that promotes unhealthy beliefs about sexuality, exploits sexuality for commercial purposes, or is sexually degrading.  degrading towards both women and men 94

95 Sex and the Media  media that is legal can be used for unhealthy purposes.  use legal pornography to prime deviant fantasies.  possible to use material that is not usually thought of as pornography to prime deviant fantasies. E.g. TV shows, movies, commercials or magazine ads 95

96 AutobiographyandDisclosure 96

97 AB & Disclosure  AB outline handed out during the second intro session  Given specific deadline (i.e., first disclosure will occur…)  Meet with therapist a couple of times to discuss and track progress  Less than 10 pages too short, more than 30 too long 97

98 AB & Disclosure  includes information regarding times in their lives where they have engaged in criminal behaviour  also periods where they have managed to remain crime free.  What was going on when things were going well vs. when things were going poorly 98

99 AB & Disclosure  Disclosure – one session per offender  minutes presentation, break then questions ~ 30 minutes  Content of disclosure –brief personal background –Relationship history –Offences – but no specific detail 99

100 AB & Disclosure  Questioning – by all group members  Clarification  Supportive challenging of minimization/denial  Not confrontational – Marshall, Marshall, Serran & O’Brien (2011) – therapists who present as warm, empathic, rewarding and directive, but not confrontational most effective 100

101 AB & Disclosure  Goal of these exercises/sessions to increase accountability/openness about offending/sexual deviance  NOT looking for the “truth”  Official version not the true version of events –Trauma effects recall –Reconstructive nature of memory 101

102 AB & Disclosure  DO NOT expect offender’s account to match the official version  plausible explanation of offence that does not include victim blaming and that acknowledges impact  Is this approach effective in terms of increasing accountability? 102

103 103

104 AB & Disclosure 104

105 AB & Disclosure  Slight nonsignficant tendency for men discharged from treatment to deny –E.g. 36% of discharged deny facts pretreatment compared to 26% of completers 105

106 AB & Disclosure  Who gets discharged?  attrition table.rtf attrition table.rtf attrition table.rtf  only disruptive behavior predicts discharge 106

107 107

108 BSEWalddfpExp B Static-99R Denial of Impact – full acknowledgement Denial Of Impact – some acknowledgement Denial of impact – no acknowledgement Denial of sexual motivation – acknowledgment Denial of sexual motivation – some acknowledgement Denial of sexual motivation – no acknowledgment

109 Cognitive Distortions  Cognitive distortions component  Focus on becoming aware of distorted thinking  Both generally criminal and associated with sexual offending  Challenging cognitive distortions without being confrontational.  Use the group process 109

110 Cognitive Distortions  What information has the client previously provided which is contradictory to the distortion?  What is the evidence for the thought?  Remain neutral. 110

111 Cognitive Distortions  Use of ACT model to challenge distortions 1) 1)Awareness of distorted thinking. 2) 2)Choose to think rationally (what is true, what is not). 3) 3)Take action - Replace with appropriate thoughts. 111

112 Cognitive Distortions  Important notion re: cognitive distortions is the idea of excuse making  Mann & Maruna (2006; Mann & Ware, 2012) – normal human tendency toward excuse making – excuse making is “the process of shifting causal attributions for negative personal outcomes from sources that are relatively more central to the person’s sense of self to sources that are relatively less central” p

113 Cognitive Distortions  ‘fundamental attribution error’ … many of the rationalizations and minimizations offered by offenders may be situational rather than dispositional.  “When challenged about having done something wrong, all of us reasonably account for our own actions as being influenced by multiple, external and internal factors. Yet, we pathologize [offenders] for doing the same thing.” p

114 Cognitive Distortions  No win situation:  “If they make excuses for what they did, they are deemed to be criminal types who engage in criminal thinking. If, however, they were to take full responsibility for their offences – claiming they committed some awful offence purely ‘because they wanted to’ and because that is the ‘type of person’ they are – then they are, by definition, criminal types as well.” p

115 Cognitive Distortions  Zuckerman (1979) – people make predominantly external attributions for our failures and predominantly internal attributions for our successes.  Argue that we need to be more sophisticated in our approach to cog. Distortions  115

116 Cognitive Distortions  excuse making is a highly adaptive mechanism for coping with stress, relieving anxiety and maintaining self-esteem.  Those who assume full responsibility for their failings put themselves at risk of suffering depression. 116

117 Cognitive Distortions  ‘revised helplessness theory’ (Abramson, Seligman, and Teasdale,1978) individuals who have an explanatory style that invokes internal, stable and global attributions for negative life events (and external, unstable and specific attributions for positive events) will be most at risk when faced with unfortunate circumstances, such as the loss of a job or a relationship breakup. 117

118 Cognitive Distortions  Hanson & Morton-Bourgon (2004) no relationship between denial of sex crime or minimizing responsibility and recidivism  However more recent research has shown that there is a relationship between denial and recidivism for some offenders 118

119 Cognitive Distortions  Also note that there is no evidence to support the notion that cognitive distortions (as distinct from offence supportive attitudes) predict recidivism 119

120 120

121 BSEWalddfpExp B Static-99R Denial of Impact – full acknowledgement Denial Of Impact – some acknowledgement Denial of impact – no acknowledgement Denial of sexual motivation – acknowledgment Denial of sexual motivation – some acknowledgement Denial of sexual motivation – no acknowledgment

122 Cognitive Distortions  it could be that offenders attempting to rationalise their deviant behaviour may exhibit other low-risk characteristics and feel a need to justify their atypical behaviour, whereas offenders admitting their deviant actions may see no need to justify behaviour that is consistent with their internal representations of self. 122

123 Cognitive Distortions Cognitive Distortions that Impede Empathy  Do not have victim empathy/empathy training component  Mann et al. (2011) – victim empathy not associated with recidivism 123

124 Cognitive Distortions  Instead discuss cognitive distortions that impede empathy  View videos to illustrate victim impact  Discuss specific distortions used to shut down empathy 124

125 Attitudes  Discussion of helpful vs. harmful attitudes –How do we know?  How do positive attitudes affect our behaviour? 125

126 Attitudes  Mr. Brown was released from prison two weeks ago and has been looking for a job. He has circled yet another ad and is on his way to another interview. He has been rejected four times even though he feels that he is well qualified to do each job. Here is an example of what he is saying to himself,  "I don't know why I'm even bothering to see the boss. I've never been able to get a good job before. I'm just a fucking failure, an ex-con. I have no money left and I won't lower myself to get welfare. I won't be able to pay the rent and I'll be kicked out of my apartment. If I don't get this job, I might as well just go back to jail. I knew I'd never make it. I might as well use the rest of my money and get drunk." 126

127 Attitudes  "Why will he never be able to get a good job?"  "What does Mr. Brown define as a failure?" "Is getting a job the only way to define success and failure?"  "If there is no money left, are there other sources of money?"  "Why is getting welfare more problematic than going back to jail?"  "Is getting drunk a good coping strategy?" "What can it lead to?" 127

128 Attitudes  Identify the negative attitudes expressed  which positive attitudes could be substituted  How can these attitudes affect reintegration and relapse.  Identify attitudes related to areas such as self worth, success, using support, attitudes towards change, etc. and how these relate to thoughts, feelings and behaviours 128

129 Emotions Management  Emotions Management Component –Addresses coping with difficult emotional states – loneliness, jealousy, depression etc. –Cognitive strategies – self-talk, challenging distortions –Behavioural strategies – relaxation –Acceptance of negative emotions 129

130 Emotions Management  Awareness of emotions – how do we know what we are feeling? –Bodily signals –Self talk  Self monitoring homework  Discussion of various “high risk” emotions –Sadness, anxiety, anger, hostility, loneliness, shame/guilt, self pity 130

131 Emotions Management  Also discuss positive emotions which may place someone at risk –Distorted cognitions which accompany feelings of happiness related to success/accomplishment  Link these emotions to behavioural progression 131

132 Emotions Management Anger  Discussion of role of anger –It is a “normal” emotion – can be helpful  Cognitive and physical signals related to anger  Addressing cognitive distortions that lead to anger 132

133 Emotions Management Anger  Rating anger on a scale of 1-10 rather than using emotionally based language. What does “anger 7” look like? Why is this important?  Anger funnel discussion. 133

134 Anger Funnel Disappointment Sadness jealousy Loneliness Boredom ANGER 134

135 Emotions 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. 135

136 Emotions Management  Strategies for managing emotions –Assertion vs. aggression –Self-talk –Relaxation/mediation/mindfulness –Effective communication 136

137 Emotions Management  Sexual arousal  Discussion the notion that sexual arousal is a feeling –Can be managed like other feeling –Don’t need to act on it –Same strategies apply  Discussion of arousal management strategies 137

138 Arousal Management  Individual therapy sessions  Every offender discussion of fantasy and how it relates to offences  Sexual fantasy monitoring  discussion of specific role fantasy plays in life/offending (e.g., sex as coping)  social skills training, strategies to deal with negative emotionality (e.g., anger, depression) 138

139 Arousal Management  Fantasy/arousal modification  Covert sensitization – develop fantasy scripts – deviant and appropriate –Develop strategies for controlling arousal –In lab – monitor arousal while reciting script –Use strategies to diminish arousal – then use appropriate fantasy to generate arousal –If not successful refer to psychiatrist 139

140 Behavioural Progression  Different ways of doing BP – e.g. Yates Kingston & Ward (2010)  Prefer simple  Series of thoughts, feelings and behaviours which culminate in sexual offence  Clients to identify 7-10 such sequences  If multiple offences chose “typical” offence 140

141 Behavioural Progression  OFFENCE CHAIN EXAMPLE.docx OFFENCE CHAIN EXAMPLE.docx OFFENCE CHAIN EXAMPLE.docx  4 wife chain.docx 4 wife chain.docx 4 wife chain.docx  approach goal.docx approach goal.docx approach goal.docx approach chain.docx approach chain.docx 141

142 Behavioural Progression  Also ask for distal factors related to offending –Background factors  Abuse  Substance abuse  Relationship problems  Present to group  Constructive feedback 142

143 Social Skills Component 143

144 Social Skills Component  Majority of high risk/needs clients lack in basic social skills  Risk factors – Antisocial peers, networks and subculture –Loneliness, lack of prosocial relationships, poor job prospects, intimacy  Focusing on enhancing skills to develop/maintain prosocial relationships  Heavily focused on skill-building 144

145 Social Skills Component  Values identification –Serves as basis for much of discussion in coming components –What are my values? –making decisions, solving problems and communicating with others. –Decisions that support our values enhance our ability to solve problems and help us live pro- social lives 145

146 Social Skills Component  Communication Skills – oriented toward developing appropriate relationships –Replacing aggressive communication (which has likely been reinforcing for the client in the past) with listening skills and active listening –Emphasis on costs and benefits of aggressive communication (decision matrix) 146

147 Social Skills Component  Problem solving/Assertiveness –Recognize when they are facing a problem and develop appropriate strategies to cope (as opposed to substance abuse, violence and sex) –Skills allow them to maintain supportive relationships and end inappropriate one –Help them to keep jobs 147

148 Social Skills Component  Relationship Skills: –Emotions matter even if they are difficult to figure out. At least need to understand that they matter to other people and be able to differentiate basic emotions. –Dealing with jealousy –Negotiating consent –How to chose a partner –Avoiding impersonal sex 148

149 Relationship Skills  Disclosing criminal history to partner  Role play  Privacy circle discussion  Describes the development of relationships  From stranger to intimate  relationships develop  3-date rule 149

150 Relationship Skills 150

151 Relationship Skills  Ideal Partner – asked to describe in terms of: Appearance, Attitudes, Education, Career, Personality traits, interests/hobbies, Religion, Cultural background, –Rank importance - 1 to 8  Is their ideal partner consistent with the values they identified earlier? 151

152 Relationship Skills  What do they bring to the relationship – what can they offer  Often expect more from a partner than they themselves are able to give.  Lead to discussion of re-evaluating what their expectations of a relationship are – idea of compromise 152

153 Relationship Skills  Maintaining Relationships –Relationships require work –Face strain from change – children, job loss –Other relationships – in-laws  Show respect  Be honest and truthful  Do little things to show you care  Treat your partner as an equal  Take equal responsibility  Make time (for family, for partner, for yourself)  Be open to change  Maintain individuality/respect individuality of partner 153

154 Relationship Skills  Coping with loneliness, rejection and jealousy  Being alone vs. loneliness –What does it mean to “be alone” –Advantages of not having a partner  Rejection – what does it mean when someone rejects you? –Possible reasons for rejection –Ways to cope 154

155 Relationship Skills  Coping with loneliness, rejection and jealousy  Jealousy – what is jealousy and why do we feel it –When you don't feel good about yourself –When you are dependent on your partner for your happiness –When you don't enjoy spending time alone –When you lack social skills –When your expectations aren't being met –When you've made the wrong partner choice 155

156 Relationship Skills  Coping with jealousy  Try to determine if the jealousy is based on fact or fear  Communicate your feelings to your partner in the very beginning  Don't allow negative self-talk to get out of hand  Negotiate with your partner ways to avoid situations that perpetuate the jealousy  Seek counselling 156

157 Self Management Component 157

158 Self Management  Puts everything from program together  Remind themselves of goals/reasons for change  Identify risk factors and main coping strategies  Relapse Cues  Appropriate use of leisure time  Main sources of support  Present/discuss in group 158

159 Individual therapy component 159

160 Individual therapy component  Address issues unique to the individual not addressed in group  Follow-up on issues which come up in group  Assist with homework  Arousal work 160

161 Individual therapy component  Substance Abuse –CSC has comprehensive substance abuse programming therefore do not target directly in SOTP –Discuss role substance abuse plans in offence progression –Importance of avoiding substance abuse in risk management/prosocial lifestyle –Don’t mix substance use and sex 161

162 Individual Therapy  Importance of rapport.  Understanding that treatment with such clients is a long term undertaking.  Prepare offender for dealing with the lapses that WILL occur  Drug use  Fighting  Angry outbursts 162

163 Individual Therapy  Manipulative Behaviours –Need to keep perspective in that these can be expected with High PCL-R clients. –Need for team communication. –Meetings with the client and all those involved in manipulative communications. That way everyone hears the same thing –Behavioral contracts. –What is the client really after-Is it a reasonable request? 163

164 Program Referrals RTC WSBC Bath SOP Maintenance 164

165 Treatment Outcome 165

166 Treatment Outcome 166

167 Treatment Outcome  Sexual Recidivism for men with PCL-R scores over 25 AND Static-99 over 5 n=70 follow-up 4.5 years 15.7% new sexual conviction psychometric table.docx psychometric table.docx 167

168 Treatment Outcome % Sexual Recidivism % Any Violent recidivism RTC only (n=152) RTC + Mod (n=24) RTC+ Mod + Maintenance (n=11)

169 Community Treatment & Supervision 169

170 Community Supervision  Community treatment of high risk sexual offenders picks up where institutional treatment ends.  The aim of community treatment is not to discuss the same material as was covered in institutional treatment programs.  The goal is to apply the knowledge which offenders have gained in institutional tx. to community settings. 170

171 Community Supervision  For example, institutional treatment programs typically focus on intimacy deficits as one aspect of dynamic criminogenic risk.  Institutional programs may teach the offenders some of the communication skills, skills related to dealing with jealousy, knowledge of sexuality that will increase the odds of these clients being able to establish and maintain intimate relationships. 171

172 Community Supervision  However, it is not until these clients enter the community that the majority may have the opportunity to use these skills in developing a relationship.  Issues such as disclosure of offense history, overnight visits and having the partner meet with correctional staff all need to be addressed. 172

173 Specific Challenges with High Risk Offenders  Manipulative behaviors –Need for frequent contact with team members involved in management of the case. –Control of living environment. –Checks with employers at worksite/via phone. –Meeting with partners of offenders. –Consequences of inappropriate behaviors discussed. –When possible, suspension is avoided. 173

174 Specific Challenges with High Risk Offenders –Consequences of inappropriate behaviors discussed.  Where possible these are discussed as opportunities to learn (e.g., thinking that you can put yourself in high risk situations). –Aggressive Behaviors:  Fighting is clearly not permitted and almost always results in suspension.  Threatening and aggressive communication is discussed in sessions and contributing factors addressed. 174

175 Community Supervision  Particularly with high risk offenders, there is the need to watch for them falling into old patterns of behavior (e.g., lying about their offence history to a prospective partner, simply not informing correctional staff about the fact that they are dating someone).  We put few constraints on who sex offenders can date with exception to child molesters being involved in relationships with those who have children. 175

176 General Guidelines  For high risk offenders it is best that they be housed in a Community Correctional Centre (CCC) or equivalent.  These settings offer offenders with few means of support a place to live and provide enough money for basic needs.  Offenders must sleep at the CCC unless authorized in writing to stay elsewhere.  Team Supervision Unit (TSU) as another option. 176

177 General Guidelines  If possible, parole officers and psychology staff should be housed within the same building.  In the Toronto area all sex offenders must be assessed for treatment by staff in the psychology department.  It is assumed that, except in rare circumstances, all offenders with a recent sexual offence conviction will attend one of several sex offender specific treatment programs. 177

178 General Guidelines  Having psychology in the same building as CCC/TSU makes it easier for those who are only allowed limited access to the community to attend treatment.  Meetings between parole officers, psychology staff, parole supervisors occur on a regular basis.  STABLE 2007 is scored on offenders on a yearly basis/STATIC-99/99R is scored if not available on file  Individual therapy and/or group treatment are available. 178

179 Sex 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. 179

180 Specific Challenges with High Risk Offenders  The goal is to keep clients in the community and when suspension is necessary, release them at the earliest possible date.  There is a need to compromise with clients on a variety of issues.  Context becomes very important in decision making. –How has the offender been doing in the community to this point in time. –Are we hearing about other difficulties with client from residents at CCC. 180

181 Specific Challenges with High Risk Offenders  Substance Abuse –Decision to suspend is client and context dependent. –More serious drugs (e.g., opiates) typically result in suspension whereas there is more flexibility with less serious drugs (e.g., THC based drugs). –Issues associated with lapses/relapse addressed in detail. 181

182 Legal Issues and Impact on Treatment Decisions  In Canada legislation which is similar in principle to sexually violent predator legislation in the U.S. generally falls within two categories: –Dangerous Offender (DO) Legislation –Long Term Offender (LTSO) Legislation. 182

183 Dangerous Offender Legislation  Criteria for DO designation: –Demonstrated failure to control sexual impulses –There is a likelihood of causing injury, pain, or other evil to other persons in the future –Because of the brutal nature of the offence.  Typically reserved for offenders with extensive criminal histories.  Must be convicted of a serious personal injury offense. 183

184 Dangerous Offender Legislation  Between 1977 and 1997 upon finding an offender to be a DO a judge could sentence the offender to either a determinate or indeterminate sentence.  In 1997, the law was amended and determinate sentences were removed as a sentencing option.  90% of DOs are sex offenders.  88% have a previous record of incarceration –(2001 data used).  As of 2001 there were 280 DOs in Canada. –Fewer than 10% have been released under parole supervision. 184

185 LTSO Legislation-Impact on the Community  To provide an alternative to indeterminate incarceration for some sex offenders who, in the opinion of the court, while exhibiting a substantial risk, could be effectively managed in the community after a period of incarceration lasting two years or more  The court may impose a maximum of 10 years of supervision. 185

186 LTSO Legislation-Impact on the Community  The LTSO provisions came into force on August 1,  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. 186

187 LTSO Legislation-Impact on the Community  LTSOs do not begin until after the Warrant Expiry Date (WED) even if the offender is in the community prior to the WED.  Some, due to “dead time” end up serving sentences of days/weeks.  As a result some of these offenders are released without any treatment having been offered/received in provincial institutions. 187

188 LTSO Legislation-Impact on the Community  Many of these offenders impress as very high needs/high risk.  It is very difficult to suspend these offenders for any significant period of time unless there are new charges laid.  It is difficult/impossible to offer a high intensity sex offender treatment program in the community. 188

189 LTSO Legislation-Impact on the Community  These offenders present with many treatment needs.  In the tend to be housed at our CCC or supervised through the Team Supervision Unit (TSU).  In the community they tend to be housed at our CCC or supervised through the Team Supervision Unit (TSU).  Coordination with police  Frequent team discussions regarding these cases. 189

190 LTSO Offenders  In Ontario as of 2011 there were 178 men with LTSO –81 were in the community. –18 additional were suspended  Most of these are released to one of the CCCs. 190

191 Community Treatment Outcome  Followed 25 sex offenders released to Keele CCC in 2007  11/25 LTSO  19 were involved in treatment  Of those involved in treatment, none were suspended over an average 3.1 year follow- up.  Of the 6 who did not participate in community treatment, 3 were suspended 191

192 Community Treatment Outcome  None of these men were convicted of a new sexual offence in the follow-up period  Two were convicted for violent non-sexual offences  One of these received community treatment 192

193 LTSO Offenders  These data, which are only preliminary, suggest that even very high risk offenders can be managed effectively in the community using a team based approach.  Inpatient housing, at least at first, is typically recommended unless the individual has a prosocial and well developed support network available. 193

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