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1 Sex Offender Specific Treatment Howard Levine Ph.D., LCP Coles County Mental Health Center Mattoon, IL

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1 1 Sex Offender Specific Treatment Howard Levine Ph.D., LCP Coles County Mental Health Center Mattoon, IL

2 2 Grateful Acknowledgements Center for Sex Offender Management (www.csom.org) For their expertise and excellent training curricula used here.www.csom.org Kurt Bumby, Center for Effective Public Policy (www.cepp.com) Work on shame/guilt and other excellent slides used in this presentation.www.cepp.com Donya Adkerson, Alternatives Counseling, Glen Carbon, IL, 62034, (618) For dedication to the field and her slides on PGE use in

3 3 The Goal of Sex Offender – Specific Treatment Community protection through effective treatment and management of sex offenders in order to REDUCE THE LIKILIHOOD OF FURTURE VICTIMIZATION MISSION: NO MORE VICTIMS

4 4 Not All Sex Offenders Are The Same Majority, but not all, offenses are committed by males Sex offenders can be adolescents or adults, male or female, rich or not, white or not, straight or not, bright or not Offenders differ in preference of victim and offense, risk to offend, supervision and treatment needed Odds are the offender is family, friend or acquaintance to the victim; but not always This presentation will focus on adult male sex offenders; however, “special populations’ will be discussed

5 5 Why do most sex offenders sexually abuse? They want to (deliberate,no accident) They are interested (suspend empathy and fear of consequences) The option is unappealing Victimization is not a self esteem issue

6 6 Sexual abuse is the last step in a long effort to manipulate Victim, wife, partner and other adults Environment and family The purpose of all this is to Feed his imagination, strengthen justifications Co-opt other adults, and victim(s) Create reliable source for ongoing victimization Decrease chances of being caught or stopped Without external intervention most offenders behavior escalates and continues

7 7 Why would a sex offender change? When dire consequences are about to ensue Severe consequences have already been experienced He is reliably and credibly managed by a system (natural and official) that can intervene with personally relevant consequences before reoffense The offender has become disgusted with himself (herself) AND views his deviance as a liability, intolerable and ‘too expensive’

8 8 The Problem of Motivation It takes a different set of motivation (internal and external) to make initial change and to sustain that change Offenders are asked to change NOT to a previously more healthy state BUT to a never known/unfamiliar responsible state Big difference between compliance and change Natural and official systems can assist in compliance. Change is up to the offender

9 9 Two Facets of Sex Offender Management: Addressing both External and Internal Controls Internal Controls External Controls External Controls: Probation/Parole Supervision Polygraph Testing Registration/ Notification Use of Community Networks Internal Controls — The Four Domains of Treatment: Sexual Interests Distorted Attitudes Interpersonal Functioning Behavior Management

10 10 Differences From Other Forms of Mental Health Treatment Involuntary clients (need leverage) Victim and community focus Limited confidentiality Treatment goals set by provider Collaboration with others essential Length of treatment SPECIALITY AREA NO TREATMENT BETTER THAN BAD TX

11 11 Characteristics of Sex Offender Specific Treatment Published standards Containment approach Specialized providers Specialized assessments Group treatment is treatment of choice Individual treatment alone is rare exception Cognitive behavioral therapy Judicious use of medicines

12 12 Characteristics of Sex Offender- Specific Treatment (cont) Explicit, empirically-based model of change Expected to reduce, never eliminate, recidivism Social learning theory-based Addresses criminogenic needs Targets factors closely linked to sex offending (criminogenic needs)

13 13 What Methods are Effective? Cognitive-behavioral techniques Adult learning theory methods Positive reinforcement rather than punishment Respectful confrontation

14 14 Treatment is Skills Oriented Skills to avoid sex offending Skills to engage in legitimate activities “Skills oriented treatment” includes: Defining the skill Identifying the usefulness of the skill Modeling the skill Practicing the skill Giving feedback Practicing the skill again

15 15 How Long Should Sex Offender Treatment Last? Until recently, answers to this question were based only on opinion—there is now research that addresses this question Different offenders require different lengths of treatment Higher levels of denial, sexual deviancy, and risk require longer, more intense treatment

16 16 How Long Should Supervision of Sex Offenders Last? Different offenders require different lengths of supervision based on risk determined through specialized SOS evaluations Typically, active supervision should continue long after active treatment Offenders should have the burden to establish that they no longer require official supervision Longer is usually better

17 17 Monitoring and Quality Control of Treatment are a Must Monitoring of: Program activities Clients Containment team members Containment team protocol Natural supervisors

18 18 Treatment of the Denying Sex Offender Denial is common among sex offenders But, admitting is vital to treatment Sex offenders who do not admit at some point can’t be treated Therefore, treatment of denial is usually necessary to make a client ready for sex offender treatment

19 19 Various Forms of Denial Complete denial Victim or other blaming Denial of personal intent Minimize extent or impact Denial of planning Denial of risk to reoffend Family, community, system denial

20 20 Tools for Addressing Denial The polygraph—aimed at specific deceptions Physiological indications of deception Offenders often abandon denial Group treatment—targets four issues Eliminating cognitive distortions Facilitating engagement in treatment Challenge offenders need to protect himself Developing victim awareness

21 21 Treating Denial Focuses on its Complexity Many purposes—why offenders are often in denial Multiple pressures to deny Denial in various phases of the offense (before, during, and after)

22 22 Methods to Address Cognitive Distortions Role play explaining to a victim all the information he would need to give “informed consent” to sexual activity

23 23 Methods to Address Cognitive Distortions (cont.) Articulating the thinking errors and cognitive distortions offenders use to excuse their behavior

24 24 Increasing Victimization Awareness If sex offenders come to understand the harm they cause, they will be more reluctant to commit future sex offenses because they will find it more difficult to disregard the consequences of their actions to their victims and others

25 25 Methods to Address Victimization Awareness Videotaped programs of sexual assault victims Visits by victims to the treatment group

26 26 Involving Sex Offenders Formerly in Denial Often graduates of the “deniers’ group” Emphasis on the positive benefits of abandoning denial “If I can do it, so can you”

27 27 The Culmination of Denier’s Treatment The denier is at last permitted to discuss his own offense—many are now quite willing to do so Some therapists report that 80% of deniers admit to the offense when this approach is used

28 28 Bottom Line for Denial Admitting to a sex crime is a necessary condition for successful treatment Offenders are to be given a specified period of time to resolve their denial or risk removal from treatment Denial is inversely related to treatment progress and engagement in treatment

29 29 Sex Offender Treatment Goals and Plans Accepting personal responsibility for a complete sexual assault history Improving social, relationship, and assertiveness skills Appropriately managing anger Learning about the traumatic effects of victimization and developing empathy Learning to separate anger and power from sexual behavior Developing pro-social support networks

30 30 Sex Offender Treatment Goals and Plans (cont.) Recognizing and changing cognitive distortions Identifying and modifying sexual arousal patterns as appropriate via Behavioral interventions and/or Medication Developing and using interventions to interrupt the offense cycle Adopting non-exploitative, responsible lifestyle

31 31 Conditions for Community Supervision NO CONTACT WITH CHILDREN UNDER 18, unless approved in advance and in writing by supervising officer and provider No contact with victim(s) Not to date or befriend anyone who has children or lives with children No access or loitering near places used primarily by children

32 32 Conditions for Community Supervision, continued No employment or volunteering that includes contact with children Not possess or use any pornographic, sexually oriented or stimulating material No internet use No alcohol or illegal drug use Residence pre-approved ‘Successfully complete’ all conditions of TX

33 33 Why No Contact Orders? Sex offenders are not purists, ‘victim profile’ is a myth. Anyone weaker than an offender is a potential victim. It is more a matter of opportunity than preference. The “official record” is always wrong. Realigns incentive to cooperate in treatment. NO MORE VICTIMS. Community safety first.

34 34 ‘Crossover effect’ Gene Abel et. al, (1983) landmark study on the frequency and variety of sexual offending behavior offenders commit. The 411 offenders in the study on average over a 12 year period had attempted 581 crimes, completed 533 crimes, had 366 victims and completed an average of 44 crimes a year. These crimes included ‘hands off’ offenses. 73%+ had two or more types of deviant sexual interest.

35 35 More on crossover Freeman-Longo, ‘rapists’ 5090 incidents of sex offending 319 child molestations 178 rapes 30 ‘child molesters’ offenses 5891 assaults on children 213 rapes on women

36 36 More still; this time with polygraph Colorado DOC, sex offenders on average 2 victims by official records 165 victims after first polygraph 185 victims after second polygraph

37 37 More yet Ahlmeyer et. al., (2000) Incarcerated sex offenders (average) Official records 2 victims 5 offenses After second polygraph 110 victims 318 offenses

38 38 Crossover; gender, age and relationship Emerich and Dutton (1993, JSO) 55% assaulted both boys and girls, 47% acknowledged multiple victim relationships O’Connell (1998, community based ASO) 64% of ‘rapists’ had assaulted a child, 59% of ‘incest fathers’ admitted to victims outside of home.

39 39 Ahlmeyer, ASO Inmates, Polygraph and TX 89% crossover by relationship, gender or age 82% child molesters and 50% of rapists crossover by age 58% ‘male victim ASO’ and 22% ‘female victim ASO’ crossover by gender 86% of sample had victims in 2+ relationship classes

40 40 Contact with children: high risk behavior increased Davis et al, (1993) Of 143 incarcerated child molesters studied only 3% of those not allowed contact masturbated about a known child as compared to 60% offenders permitted contact % of incarcerated ASO with permission to visit kids in DOC waiting room masturbated about those kids. (Colorado DOC, 1999).

41 41 Sex offenders, even in treatment, are dangerous Tanner (1998) 128 ASO in first year of community based treatment and supervision 31% had sexual contact with child 25% had unauthorized contact with a child 12% had forced someone to have sex 86% was participating in new high risk behavior and/or new crimes

42 42 When to Increase Intensity of Supervision Offender in stress or crisis Offender in high risk situation Offender will have contact with potential victims Offender shows high or increased denial Offender works with internet Active treatment or probation ending soon

43 43 The Four Domains of Treatment Sexual Interests Distorted Attitudes Interpersonal Functioning Behavior Management

44 44 Sexual Interests—The First Domain of Treatment Deviant sexual arousal is sexual arousal to: Non-consenting partners Non-age-appropriate partners Acts that are abusive in nature For many sex offenders, a strong motivation to commit sexual assaults is deviant sexual arousal Not all offenders have deviant sexual arousal AROUSAL DOES NOT EXPLAIN BEHAVIOR

45 45 For Offenders with Deviant Sexual Arousal If such arousal can be decreased, the likelihood of future sex offending will be decreased Treatment goals include: Reduce deviant sexual arousal while increasing non-deviant sexual arousal Increase reactions to the offender’s deviant behavior as non-offenders react—with disinterest or revulsion

46 46 Behavioral Intervention to Reduce Deviant Sexual Arousal Based on the idea that deviant sexual arousal is “learned” behavior and can be unlearned Substitutes non-deviant thoughts for deviant thoughts Connects deviant thoughts with non-arousal

47 47 Types of Behavioral Interventions Covert Sensitization Ammonia (aversive) conditioning Masturbatory reconditioning

48 48 Common Questions about Behavioral Interventions Can offenders sabotage this? Who is this best suited for? Is this technique essential? Can this technique be used exclusive of others? Yes—but they’re only hurting themselves Offenders with significant deviant sexual arousal No—but some intervention must address deviant sexual arousal No

49 49 Goals of Covert Sensitization To reduce the attractiveness of sexual assault by having the offender focus on the negative social consequences he faces To have offenders explore all of the consequences of their actions—in particular the negative consequences which offenders so often refuse to recognize

50 50 Methods of Covert Sensitization Offenders identify the chain of thoughts that lead them to offense behavior Offenders are taught to deliberately interject vivid scenes of the negative consequences they will face during that chain of thoughts Audiotape homework provides structured practice sessions for this technique that can be reviewed by the treatment provider

51 51 Goals of Ammonia (aversive) Conditioning To reduce the strength of a deviant sexual fantasy by association with unpleasant stimuli To reduce the strength of sexual response to the deviant fantasy To facilitate offenders likelihood to escape/terminate deviant sexual fantasy

52 52 Methods of Ammonia (aversive) Conditioning Offenders identify and audiotape a powerful deviant sexual fantasy. Offenders listen to their deviant fantasy and deeply inhale ammonia at the first sign of sexual stimulation. Last step is repeated frequently across days until offender has eliminated arousal to fantasy.

53 53 More Methods of Ammonia (aversive) Conditioning Homework sessions are reviewed by treatment provider Offender eventually may carry small vial of ammonia, or smelling salts, to use in real life situations to escape/terminate deviant sexual fantasy After inhaling the ammonia the offender is to focus on non sexual thoughts and/or coping skills

54 54 Goals of Masturbatory Reconditioning Increase sexual arousal to appropriate sexual fantasies with consensual adults Weaken arousal to deviant sexual fantasies by association with boredom/non-arousal

55 55 Methods of Masturbatory Reconditioning Offender verbalizes appropriate sexual fantasy while masturbating to orgasm Immediately after orgasm to appropriate fantasy, the offender continues to masturbate to verbalized deviant sexual fantasy for 45 or more minutes Audiotape homework is reviewed with treatment provider

56 56 Pharmacological Interventions to Address Deviant Sexual Arousal There are two primary types of medications used in the treatment of sex offenders: Selective Serotonin Reuptake Inhibitors (SSRIs) Antiandrogens—used for what some call “chemical castration”

57 57 Selective Serotonin Reuptake Inhibitors Commonly prescribed for depression Reduce libido (sexual interest) They can also reduce aggression, decrease deviant fantasies, empower people to better manage their behavior, and reduce the intensity of compulsive aspects of sexual offending Many physicians are knowledgeable of and comfortable with prescribing such medications

58 58 Antiandrogen Medications Drastically reduce testosterone Reduce sex drive and the ability to have an erection “Sexual appetite suppressants” Examples include Provera and Lupron Doctors reluctant to prescribe

59 59 Incidence of Side Effects of Antiandrogen Medications Decreased sperm count—100% Increased body temperature—100% Decreased sex drive—95% Erectile dysfunction—95% Decreased amount of ejaculate—95% Weight gain—58% Increased blood pressure—50% Fatigue—30%

60 60 Side Effects of Antiandrogen Medications (cont.) Nervousness and/or depression—30% Hot/cold flashes—29% Headaches—20% Nausea—14% Gall bladder disease (sometimes necessitating surgery)—13% Diabetes—4% Phlebitis (can lead to life-threatening pulmonary emboli)—2%

61 61 Some Physicians are Reluctant to Prescribe Antiandrogens They are not approved by the FDA for the treatment of sex offenders It is outside of normal, clinical practice to prescribe to men for reduction in sexual arousal

62 62 Methods of Administration and Costs: Antiandrogens Depo-Provera Injected weekly $40 per week Provera Administered orally Depo-Lupron Injected monthly $400 per month

63 63 Is Medication Alone an Effective Treatment Method? Medication that complements the cognitive-behavioral center of treatment can be very helpful in facilitating treatment—5 to 30% can benefit If our goal is to reduce recidivism, and medication will help maintain an individual long enough to help him assimilate the cognitive-behavioral response, it is irresponsible not to use it Conversely, given the current body of evidence, it would be irresponsible to only medicate and not include a cognitive-behavioral treatment component

64 64 Distorted Attitudes—The Second Domain of Treatment Purpose—to identify and alter offenders’ justifications for sex offending One approach is through cognitive restructuring By examining and exposing these thoughts, justifications, rationalizations, and excuses, the offender is challenged to understand his faulty thinking and recognize its distorted, self-serving nature

65 65 Cognitive Restructuring Examine rationalizations, excuses, and cognitive distortions Obtain candid feedback on these distortions from others Heighten awareness of victimization issues Recognize the faultiness of his thinking Confound his ability to justify future offending Assists offenders to:

66 66 Thinking Errors of Sex Offenders: SOBS Offenders, in order to sexually abuse another person, have changed their way of thinking so that molesting another is not the same as others believe. Offenders think in ways that have made their sexual assault harmless, ‘OK’ or deserved. SOBS is also used to justify the behavior after the fact and support the offenders self-centered approach to meeting his needs. Offenders fight hard to justify and maintain their SOBS.

67 67 Some Examples of SOBS Excuses; anything to avoid accepting personal responsibility Blaming; excuses with a bad attitude Seeking sympathy; feel sorry for me Justifying; Yes, but….. Re-defining; shifting the focus of an issue to avoid solving a problem Pet Me; notice me, cuddle me, applaud me

68 68 More Examples of SOBS Lying; complete, partial, phoniness Uniqueness; I am not like the others, this can’t apply to me Minimizing; At least I didn’t….. Anger; to manipulate or distract others Victim stance; so others will rescue or forgive him Helpless; I can’t … so don’t ask Arrogance and what is in it for me; bottom line

69 69 Methods of Cognitive Restructuring Examine role of distortions in non-sexual situations Offenders anonymously relate the distortions they have used in the past Role playing of victim, victim’s parent, long-time friend of offender, probation/parole agent Debrief role plays The power of the group

70 70 Rationale for Victimization Awareness/Empathy Training Most offenders victimize for selfish gratification If sex offenders learn about the true consequences of their actions for victims, this confounds their ability to discount the trauma that their actions create and maintain their SOBS Many offenders do not have a generalized empathy deficit However, most sex offenders have little empathy for their victims If they learn, they will be less able to ignore/discount the trauma their victims suffer

71 71 Goals of Victimization Awareness/Empathy Training To understand the pervasive negative effects of sexual assault on victims and others To know the consequences of his assaults (past and future) on his victims and others To learn empathy skills, especially the ability to empathize with his victims To make re-offending more complicated, less enjoyable

72 72 Practice Implications SOS treatment programs should assess and target the specific empathy deficits of each offender Important to ensure that the offender does not harbor hostility toward their victim before providing training in victim awareness. Such awareness is valuable only in a caring or benign relationship Contraindicated for sociopath/psychopaths

73 73 Practice Implications (cont) Providers should carefully consider the value of their existing empathy training program. Misdirected interventions would be expected to have no effects, or detrimental effects, on the offenders sympathetic, compassionate, responses to victims.

74 74 Methods of Victimization Awareness/Empathy Training Presentation of information on the typical trauma to sexual assault victims Use of audiovisual materials Written assignments Group education and confrontation by adult sexual assault survivors Role play

75 75 Each offender describes his worst offense from the victim’s perspective Introduces his victim by first name and age Describes how he accessed and groomed the victim Describes what he did to influence the victim not to report Discusses how the victim is doing now Postulates what the victim would like to say to him or ask him now Methods of Victimization Awareness/Empathy Training (cont.)

76 76 Interpersonal Functioning—The Third Domain of Treatment Why is this important? Persons with poor social skills may, out of frustration: Overpower victims, or Retreat to the lower stress environment of children Improved social skills and success can reduce the need to resort to abusive behavior to interact with others or meet emotional needs

77 77 The Goals of Increasing Interpersonal Functioning Meeting strangers Initiating and maintaining conversations Correctly interpreting non-verbal communication Developing appropriate non-verbal skills Understanding appropriate methods of indicating interest and disinterest Managing anxiety To increase social skills in:

78 78 Appropriate personal disclosure Transitioning from social to social-sexual interactions Maintaining friendships Respecting women and children Understanding the importance of addressing attention to others beyond one’s self The Goals of Increasing Interpersonal Functioning (cont.)

79 79 Methods of Social Skills Training Presentations on relevant topics Role play various types of social settings/interactions Behavioral assignments with reports back to the group

80 80 Rationale for Assertiveness Training Assertiveness increases self-esteem, reduces shame and anger, and increases satisfaction in interpersonal interactions Sex offenders often suffer from shame and/or anger when they assert themselves They often store up slights, humiliations, and react with inappropriate anger—sometimes contributing to violent sexual abuse

81 81 Goals of Assertiveness Training Learn that the primary purpose of assertiveness is not to change others’ behavior but rather to increase self-respect Reduce fear, shame and anger in interpersonal interactions Increase appropriate self-respect and self- esteem Improve effective interpersonal interactions Teach specific assertiveness skills

82 82 Methods of Assertiveness Training Presentation on relevant topics Clarify differences between assertiveness, passivity and aggression Role play various social situations or settings Behavioral assignments with reports back to the group

83 83 Shame vs. Guilt ( Kurt Bumby, 2003) Shame Focus on ‘bad self’ Self as unchangeable Self-focus reduces empathy Feel exposed and scrutinized Defensive externalization Hostility, low esteem, hopelessness Cripples coping response Leads to entitlement Guilt Focus on ‘bad behavior” Views behavior as changeable Promotes sense of responsibility Discomfort from impact of behavior on others Optimism and self efficacy increases Motivates commitment to make amends and personal change

84 84 Rationale for Sexual Values Clarification Training Many sex offenders have deficits in sexual knowledge They may commit offenses in part because they have unreasonable expectations of their sexual functioning, have high anxiety in sexual situations, or have had negative experiences with consenting sexual partners

85 85 Goals of Sexual Values Clarification Training Increase knowledge about basic, healthy sexual functioning Promote positive, respectful attitudes toward women and children Educate about normal sexual attitudes, behavior, and performance Reduce anxiety about sexual matters Increase information about sexually transmitted diseases

86 86 Behavior Management—The Fourth Domain of Treatment Sex offending is a choice made by the offender. Relapse prevention is also a choice. Both require commitment, consistently reaffirmed, to the goal. Effective treatment and supervision can assist and encourage the offender to behave in responsible and non-victimizing ways.

87 87 Relapse Prevention First used in the treatment of alcohol and other drug abuse If behavior could be managed to avoid certain situations, then relapse was less likely Applied now in the treatment of sex offenders

88 88 Rationale for Relapse Prevention Sex offenders who believe that treatment will eliminate their risk for reoffense are more likely to recidivate Offenders who understand that they are never “cured,” recognize offense precursors, and avoid high risk thoughts, feelings, and behaviors are more likely to remain offense free Others must also accept this risk to reoffend

89 89 Relapse Prevention Cycle

90 90 Goals of Relapse Prevention The sex offender must learn: That prevention of new offenses is a life-long process and daily choice That certain situations, thoughts, or chains of events pose high risk for re-offense and must be avoided or managed That seemingly unimportant decisions can lead to re- offense That risk to re-offend is not static To respect/fear his risk to reoffend

91 91 Goals of Relapse Prevention (cont.) Perception of control Introduction of a negative mood state Engaging in fantasies of reoffending Development of a plan to commit the offense (Often) use of disinhibiting substance RELAPSE The sex offender must learn the typical sequence of events that lead to relapse:

92 92 Goals of Relapse Prevention (cont.) The sex offender must learn that: If he interrupts this sequence with positive coping, he can reduce the likelihood of reoffending A lapse is the occurrence of any step in the sequence short of reoffending Interrupting the pre-offense behavior cycle is easiest to do in its early stages

93 93 Methods of Relapse Prevention Dispel offenders’ misconceptions about their reoffense risk—IT’S STILL THERE Identify and share high risk factors and relapse indicators Refine avoidance and coping skills and strategies Design plan to avoid first lapse and how to prevent a lapse from becoming a relapse Learn self-monitoring of moods and behaviors Inform, motivate and empower supervisors

94 94 Methods of Relapse Prevention (cont.) Write an autobiography to understand life patterns that result in offending Teach problem-focused coping responses Control stimuli that might promote relapse Teach the relapse process Teach that urges subside with time Teach avoidance and escape strategies

95 95 Methods of Relapse Prevention (cont.) Teach relapse rehearsal Promote lifestyle changes Identify prosocial methods to express power

96 96 Examples of High Risk Factors Angry Lonely Tired Bored Frustrated Rejected Confused Unhappy Pressured Potential victims Alcohol and/or drugs Some TV or movies Pornography Alone, unsupervised Money problems Relationship problems New freedom Pain or poor health

97 97 Examples of Relapse Indicators Absence of appropriate sexual activity Denial of risk to reoffend Distance from supervisors, associating with those who don’t know or don’t care Using alcohol or drugs SOBS Testing oneself Unstructured or unmonitored time Change in routine, appearance or demeanor Access to potential victims

98 98 Ethical Practice Standards Balancing the safety of the community with the offender’s privacy Informed consent Association for the Treatment of Sexual Abusers (ATSA) is the major professional organization that speaks to ethical practice standards in this field ATSA has issued a “Code of Ethics” as well as practice standards and guidelines

99 99 A Major Ethical Issue: Informed Consent At a minimum, sex offenders entering treatment should have spelled out to them—preferably in writing: The purpose and nature of treatment Its expected duration Its anticipated benefits, costs, and risks Limitations of confidentiality

100 100 Adjunctive Therapies Marital and family therapy Family education seminars and couples’ groups ‘Non-offending spouse’ groups ‘Approved supervisor’ groups Substance abuse treatment Educational/vocational supports Individual therapy (usually for other issues)

101 101 Mental Illness and Sex Offenders Most sex offenders are not mentally ill Some sex offenders are mentally ill Most persons with a mental illness never offend Persons with a mental illness are more likely to be victims than offenders Mental illness does not cause or explain sex offending

102 102 Paraphilias Category of mental illness sometimes diagnosed in sex offenders Essential feature is a ‘recurrent, intense sexually arousing fantasies, sexual urges, or behaviors (at least 6 months) generally involving: Nonhuman objects Suffering or humiliation of self or other Children or nonconsenting adults’

103 103 Paraphilias (cont) ‘The behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.’ For some individuals, these paraphiliac fantasizes or stimuli are essential for sexual arousal. For others, paraphiliac preference is episodic only.

104 104 Types of Paraphilias Exhibitionism; exposure of genitals Fetishism; use of non living objects Frotteurism; touching/rubbing against nonconsenting person Pedophilia; focus on prepubescent children Sexual Masochism or Sadism; receiving or inflicting humiliation or suffering Transvestic Fetishism; cross-dressing Voyeurism; observing sexual activity

105 105 Paraphilias and Sex Offending Exhibitionism, voyeurism and pedophilia are the most frequent paraphiliac diagnosis among identified sex offenders These behaviors are by their nature unlawful

106 106 Exhibitionism With or without public masturbation, Usually not physically assaultive, Often begins in adolescence, Frequency of arrests decrease after 40

107 107 Voyeurism Usually not physically assualtive Often begins before 15 Often chronic in nature

108 108 Pedophilia Prepubescent children, 13 y/o and younger Offender 16 y/o or older, 5 year plus age difference between offender and victim Specify Exclusive vs. Non exclusive Males, Females, Both Limited to incest

109 109 Sexual Dysfunctions Premature Ejaculation Male Erectile Dysfunction Hypoactive Sexual Desire Disorder Male Orgasmic Disorder Dyspareunia Subtypes Lifelong vs. acquired Generalized vs. situational Psychological vs. combined factors

110 110 Personality Disorders Enduring pattern of inner experience and behavior that markedly deviates from cultural expectations. Two or more; cognition, emotions, interpersonal functioning, impulse control Inflexible and pervasive across situations Clinically significant distress or impairment Stable, long duration (adolescence) NOT another MI, substance abuse, medical

111 111 Antisocial Personality Disorder Pervasive pattern of disregard for and violation of rights of others. Since 15 y/o, 3 or more of Repeated criminal acts Deceitfulness, lying, aliases, conning Impulsivity, failure to plan ahead Irritability/aggressiveness, fights/assaults Reckless disregard for safety (self/other) Consistent irresponsibility, work history Lack of remorse or indifference to harm caused

112 112 Antisocial Personality Disorder (cont) Over 18 y/o Conduct Disorder by 15 y/o Sociopathic/psychopathic as extreme version

113 113 Other Mental Illness Major Depressive Disorder Bipolar Disorder Posttraumatic Stress Disorder Psychotic or Delusional Disorders Other Anxiety Disorders Social Phobia Generalized Anxiety Agoraphobia

114 114 Mental Illness and Offending Mental Illness is often used as excuse, justification, or a description of criminal acts Many MI complaints follow or increase after arrest Most MI complaints decrease dramatically with SOS treatment

115 115 Mental Illness and Insanity Insanity is a legal concept regards culpability or diminished capacity All criminally insane individuals are MI, very few individuals with a MI are insane Criminally insane individuals are not able appreciate their behavior as unlawful or conform their behavior to the law

116 116 Substance Abuse and Sex Offending Some addicts/alcoholics are sex offenders, most are not Alcohol/drug use can increase risk Sobriety increases safety Most offenders are sober at time of abuse Some recovering addicts/alcoholics continue to sexually abuse Successfully drug/alcohol treatment is essential but not sufficient

117 117 Treatment Progress and Provider Characteristics Treatment has been found to reduce recidivism (Hanson et al 2002) Treatment failure increases recidivism (Hanson & Bussiere 1998) High risk offenders are less compliant with treatment and supervision (Hanson & Harris 1998)

118 118 Treatment Progress and Provider Characteristics (cont) Denial and engagement together significantly correlated with treatment progress In combination, engagement and denial explained close to 60% of the variance in treatment progress Engagement was a stronger predictor then denial (Beta.52 & -.37, respectively) Levenson, 2003

119 119 Treatment Provider Characteristics In the past, sex offender treatment has often involved a punitive treatment style characterized by aggressive verbal confrontation between offender and therapist (therapeutic reaming) Studies have examined how therapist styles affect the success of treatment: Marshall et al., Clinical Psychology and Psychotherapy (In Press) Marshall et al., Journal of Sexual Aggression (In Press) Jill Levenson, ATSA 2003

120 120 Treatment Provider Characteristics (cont.) Some treatment targets seem to be better achieved with the use of treatment delivered with a motivational approach based on empathic understanding, mutual trust and acceptance. Reduction in sense of entitlement to sexual gratification Reduction of mistrust of women Reduction in impulsivity Client engagement

121 121 Practice Implications Providers should consider a positive, invitational and motivational style that supports offender engagement in group Setting expectations for mutual aid and modeling effective communication and helpfulness will foster engagement Group members can take a major role in confrontation which may reduce shame and fears of judgment or rejection. This approach may reduce the salience of the protective function of SOBS and denial

122 122 Choosing SOS Evaluators and Treatment Providers Lack of standardized certification or other credentialing in most jurisdictions presents a major difficulty in promoting common standards of practice

123 123 However, in Illinois… The Illinois Sex Offender Management Board (www.ag.state.il.us/communities/somb/index.html) has published standards for the evaluation, treatment and supervision of adult sex offenders. Also, there is an interim list of individuals that have met SOMB qualifications for SOS evaluators and/or providers

124 124 SOMB Interim Qualifications for SOS Providers Bachelor’s degree or higher in relevant field 400+ hours of supervised experience in last 4 years, at least 200 face-to-face Completed 10+ SOS evaluations in last 4 years 40+ hours documented training in the specialty of sex offender specific assessment, treatment or management Provide SOS evaluations and/or treatment in accordance with SOMB standards of practice

125 125 SOS Providers as Collaborative Partners A willingness to collaborate and cooperate work with other professionals, including: Probation and parole officers Victim Advocates Polygraph examiners Other evaluators and treatment providers Attorneys, prosecutors, and other criminal justice representatives

126 126 Special Populations Juvenile sex offenders Female sex offenders MR/DD sex offenders

127 127 Juvenile Sex Offenders Similarities to Adult Offenders Victimize others SOBS Empathy deficits Impaired interpersonal functioning Not all alike, don’t all need the same thing

128 128 Juvenile Sex Offenders Differences from Adult Sex Offenders Don’t belong in ASO treatment program Psychopathy less common Deviant arousal less common Interpersonal competency and esteem problems more significant Juveniles may be more amenable to and benefit more from appropriate SOS treatment

129 129 From Juvenile to Adult Sex Offender Not all juvenile sex offenders will become adult sex offenders Long term risk for competently treated juvenile sex offenders is encouraging High value on identifying and properly managing juvenile sex offenders Not all adult sex offenders were juvenile sex offenders

130 130 What about children? Children can and do behave in sexually aggressive ways that hurt others However, it is not usually appropriate or helpful to label them as Sex Offenders Specialized assessment, intervention and management is indicated Sexually aggressive/reactive children should not be placed or treated with Juvenile Sex Offenders

131 131 Female Sex Offenders Adult females Account for 10-20% of sexual abuse of children Care-giving context Socially isolated Attachment issues History of PTSD, addiction and MI Victimized 2X male ASO Adolescent females Much more likely victimized sexually Emotional abuse and neglect victims Physical and domestic abuse Use less force or coercion Abuse in care-giving context

132 132 Female Sex Offenders Don’t typically belong in male sex offender programs Not all alike, don’t all need the same treatment program More research and programs needed Hurt people Often overlooked by community,courts and providers

133 133 MR/DD Sex Offenders Offenders with significant functioning deficits need specialized treatment from specialized providers Inappropriate to place in program that doesn’t fit their needs or to forego treatment all together Environmental management important Increase premium on the commitment and dedication of supervisors, natural and official

134 134 Use of Polygraph Examination in SOS Treatment; Why? Very few people (therapists, judges/lawyers or probation officers included) are much better than chance at telling when they are being lied to Most people think they are an exception to this rule Sex Offenders lie Polygraph Examination (PGE) is better than chance and we don’t have anything better

135 135 Utility of PGE in Treatment Encourages offenders to disclose earlier and more completely Improves detail and accuracy of risk assessment Improves safety planning and decision making Motivates offenders to avoid high risk behavior Improves safety for community and victim PGE improves community safety and enhances treatment efficacy by increasing amount of accurate and timely information

136 136 Concerns About PGE in SOS Treatment PGE is not 100% accurate PGE accuracy is affected by skill of examiner PGE cost money Not appropriate to base important decisions on PGE results alone. All information available must be considered

137 137 Response to Concerns About PGE Use NO test is 100% accurate, most test are more easily faked, accuracy is much higher than human detection of deception SOMB standards demand specialized training and experience for examiners Costs are offset by faster movement in treatment and better success rates for programs using PGE It is not responsible practice to ignore any reliable source of information in making important decisions

138 138 Accuracy of PGE Computerized equipment and scoring have improved accuracy Strength of motivation in the offender examined improves accuracy (If the offender believes the results of the exam matter the results are more accurate) 52 lab studies; median accuracy of.86, range of.70 to.95 Field studies, although more difficult, show higher accuracy, median of.89

139 139 Factors Affecting PGE Accuracy No significant differences in accuracy found in exam subjects based on; Personality disorder Intelligence (assuming at least 12 y/o level) Ethnicity Number of PGE taken already History of anxiety disorder or high levels of anxiety at time of test

140 140 Who Should Be Excluded From PGE? Actively psychotic or out of contact with reality Physically illness or medication that renders PGE unreadable Presence of acute pain or illness Presence of acute, severe, distress Adjusting to recent (last 2-3 weeks) medication change

141 141 Types of PGE Used in Treatment History disclosure Maintenance/monitoring Specific issue All include pre and post exam interviews All PGE are limited to only a few (3-5) specific questions, chosen in consultation between provider and examiner. Offenders are informed of these questions prior to the exam.

142 142 History Disclosure PGE Purpose is to obtain complete history of offending. Essential for risk assessment, safety planning, treatment planning. Offender, with provider, completes a history booklet before PGE PGE tests the accuracy and completeness of previous disclosures Sometime additional exams are required

143 143 Maintenance and Monitoring PGE Purpose is to improve compliance with supervision and safety planning, and to identify any problems (non-compliance) with same PGE covers specific behaviors of the offender within a specific time frame Important for identifying current risk behaviors before new offense occurs Serves to motivate offenders to avoid high risk as they fear detection of the behavior

144 144 Specific Issue PGE Purpose is to detect deception/truthfulness regarding a specific incident This narrow focus allows for the highest level of accuracy among the types of PGE discussed

145 145 Assessing Treatment Progress Accurate information and consistent observation across time are essential in assessing an offenders progress in treatment Since offenders lie it makes no sense to use their report as the sole source of information in assessing progress Rather, the offenders behavioral change across time and situations, confirmed by PGE, is the standard

146 146 Tools for Assessing Progress Critical and cynical observation across time Consultation with containment team and others PGE Various instruments may be of use Sex Offender Treatment Needs and Progress Scale (McGrath & Cumming, 2003) Facets of Sex Offender Denial (Schneider & Wright, 2001) Group Engagement Measure (Macgowan, 1997) Sex Offender Rating Scale (Anderson et al, 1995)

147 147 Change in Behavioral Restrictions Only after sufficient progress in treatment Only with collaboration with team Only with specific safety plan Only with increased supervision Only with monitoring PGE

148 148 Completion of Treatment Completion of treatment does not imply the end of supervision or elimination of risk to the community Treatment should be viewed as ranging from intensive to aftercare If risk increases, treatment should be re-instated

149 149 Completion of Treatment (cont) The containment team should consult about the completion of treatment The decision should come after the evaluation, treatment plan, course of treatment sequence, and a minimum of a non-deceptive disclosure PGE and two or more non-deceptive maintenance PGE regarding compliance with probation/parole orders, treatment contract and avoidance of high risk situations

150 150 Unsuccessful Termination from Treatment Increase in risk such that continued placement in the community is not safe Reoffense Repeated refusal to comply or engage in treatment process despite sanctions Refusal to accept identity as sex offender

151 151 Personally Relevant Circumstances Strict adherence to letter and spirit of probation order and SOS treatment contract Initiate consequences early and hard Range of consequences Keep court/judge informed of progress or lack of Consider PTR with jail time plus new term of probation for significant violations that no not necessitate termination

152 152 Contact with Children or Family Reunification ONLY IN BEST INTEREST OF CHILD Only after sufficient progress in treatment Only with “approved supervision” Only with increased monitoring and PGE Only with strict and specific rules and restrictions Only with regular and ongoing coordination with victim advocate or family therapist

153 153 Summary We’ve reviewed sex offender treatment History, current practices, most effective methods, particular techniques and style, and length of treatment The four domains of sex offender-specific treatment: Sexual Interests Distorted Attitudes Interpersonal Functioning Behavior Management Your heightened understanding of sex offender-specific treatment will enable you to work more effectively and collaboratively with treatment providers


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