1. Working with IDD Sex Offenders Michael Gavetti

2. Introduction IDD Offenders are neither fish nor fowl:
Serious crimes, but often not competent to stand trial.
End up on locked long-term state institutions (with no SO treatment available).
No specialized community programs, so they end up locked up forever without having a trial.
Alternative is to release them without appropriate supervision– agencies often refuse to accept them.
Some recipients commit offenses, but because they are not prosecuted or institutionalized, the information about their offenses is lost, omitted, deleted, or simply missing.
Means that there are many unidentified IDD offenders in the community.

3. What are some differences in Tx for different types of sex offenders?
Most adults are referred from the criminal justice system, and are obligated to attend and participate in Tx as a part of their probation/parole (nonparticipation=incarceration).
Most adolescents are referred and treated within the MH system (juvenile courts are often involved). They are often referred to RTFs where attendance is mandatory, but there is no way to enforce participation.
Many IDD adults never stand trial, and are overseen by DMRS. They are often under no obligation to attend or participate in treatment.

4. How are IDD offenders likely to come to your attention?
Juvenile offenders aging out of the system, now in need of adult services.
Families who had been coping with offending behaviors on their own no longer able to support their IDD SO children.
Changes in SO law/community attitudes may mean that previously ignored offenses now reported to the authorities.
Lawsuits pushing some offenders out of long-term treatment facilities.

5. Why don’t we know more about which IDD recipients are sex offenders?
Data never tracked by state
No comprehensive information files for recipients
Direct care staff sometimes reluctant to document sexual behaviors
Police reluctant to arrest recipients who have DMRS services
Courts unwilling to prosecute cases that will not lead to conviction (i.e., some recipients not competent for trial)
ISC’s reluctant to mention inappropriate sexual behaviors in plans
Family/advocates attempt to soften/delete historical information to limit bias
Information “lost” to facilitate referral/transition process
Even if ID’d, trouble getting recipients connected to appropriate services

6. What barriers do SO Tx providers face when working with IDD clients?
Nation-wide/ state-wide lack of knowledge about how to treat sex offenders (including a lack of research-based programs for working with sex offenders)
Criminal justice system shortfalls for addressing SO behaviors in IDD offenders
Most SO providers have less experience working with IDD recipients than with non-IDD populations (and no empirically-based programming materials)
Funding (many IDD offenders are indigent)

7. What barriers do IDD providers face when working with SO clients?
Lack of local sex offending treatment resources for the IDD population
Lack of IDD service personnel with SO experience (at all levels—management, clinical, direct care)
Lack of willingness to confront SO issues directly (e.g., conflict between traditional IDD values and SO treatment recommendations)
Cultural reluctance to discuss sexual issues for IDD populations
Fear of liability issues

8. What is DMRS? Division of Mental Retardation Services
Located within the Tennessee Department of Finance and Administration
(from the web page) DMRS is the state agency responsible for providing services and supports to Tennesseans with mental retardation.
DMRS provides services directly or through contracts with community providers in a variety of settings. These settings range from institutional care to individual supported living in the community.
There are three long-term care facilities in the Division system: Arlington Developmental Center in Arlington, Clover Bottom Developmental Center in Nashville, and Greene Valley Developmental Center in Greeneville.
Regional offices located in Memphis, Jackson, Nashville, Chattanooga, Knoxville, Greeneville and Johnson City work with community agencies to provide services.

9. How is DMRS useful to you?
Being enrolled in DMRS services gives the client access to healthcare coverage, case management, and other supports.
DMRS supported living agencies can provide 24/7/365 supervision (at 1:1 or 2:1 staffing levels) for identified offenders.
Some DMRS provider agencies can provide educational help and/or social skills training.
DMRS services represent a real alternative to traditional criminal justice interventions.
West TN DMRS has a work group that can help facilitate connection to specialized services (SBRRC)

10. What are some complexities to working within DMRS?
Educating the Circle of Support (COS)
Collaborating with the provider agency
Helping client families who may be in denial
Assisting providers as they try to navigate the HRC (Human Rights Committee) and ISP (Individual Service Plan) processes

11. DMRS cultural concerns
Inertia of DMRS system is towards individual choice and autonomy– providers are reluctant to limit choice or restrict SO recipients
Providers sometimes tempted to compromise structure in the face of family pressure
24/7 staffing, high employee turnover– high risk for miscommunication between shifts
Significant limits to what can be “imposed” on recipients without their permission
System is ISP driven

12. What type of structure should SO Tx providers be facilitating/advocating?
Highly structured & consistent environment
Trained staff with clear communication systems
Integrated treatment services (both for SO and non-SO issues)
Consistently enforced restrictions that maximize both safety and appropriate choice
Close collaboration with other involved institutions/programs (including DMRS)

13. What is the current standard of care?
The TN SO Tx Board subscribes to a “lifetime supervision” model.
Means that although sex offending can be treated, there is no “cure” and the person will always have at least some risk for re-offending.
Supervision requirements and treatment goals are driven by client-specific factors, such as global risk for re-offense, progress in treatment, and type of offending pattern.
As the person progresses in treatment, less supervision is required in order to minimize re-offending risk.

14. What sort of SO Tx content should be covered for IDD clients?
Same as for other adult offenders (TN SOTB curriculum)
Life history, including full disclosure of all sex offenses (supported by polygraph, if possible).
Anger management (often a trigger).
Cognitive restructuring (to alter schema that support offending)
Communication/Assertiveness (offending is a maladaptive coping response for some offenders)
Relapse prevention
Sexual reconditioning (to alter deviant arousal patterns)
Victim impact/empathy

15. Clinical Treatment Differences (Ability)
Literacy problems
Limited memory
Difficulties with abstract reasoning
Empathy and cognitive development (Kohlberg, Piaget, Erikson, etc.)

16. Clinical Treatment Differences (History)
Sometimes sheltered from consequences of their actions
Sexual education deficits
Long histories of institutionalization
Few or no historical experiences with healthy sexuality (often have little experience with healthy adolescent dating)
Sometimes been taught to “play dumb” as a defense

17. Clinical Treatment Differences (Current lifestyle)
Limited social supports
Limitless unstructured free time
Limited finances
Social skills deficits
Naive perceptions of complex relationships
Generalized belief that all sexual behaviors are bad (i.e., will get you in trouble or are “nasty”)
Limited opportunities for current healthy adult sexual relationships

18. Clinical Treatment Differences (Therapy)
Pace of sessions is slower
Duration of treatment is longer
Greater emphasis on repetition and psycho-education
Progress occurs in smaller increments
Emotional work more basic (often starts with emotional identification)
Multi-step interventions often impractical
Homework often difficult to implement
Real-life examples more effective than metaphor or abstract imagining

19. How do you prepare an IDD client for SO group treatment?
Explain environmental structure multiple times (programmatic, therapeutic, criminal justice)
Ensure that restrictions have been approved by HRC and added to ISP
Gather information in detailed SO history (usually requires in-depth review of documentation and involves multiple individual sessions), and prep to discuss Hx in group
Create SO group introduction using the offender’s own words (respectful language only)
ID the recipient’s offense pathway

20. Introduction Example
An example introduction from the Sex Offender Group (taken verbatim from his own disclosures whenever possible):
“My name is XXXXX. So far I have told about three victims. My first victim was a 6-year-old girl that I knew from my old neighborhood. I got close to her by helping her to fix her bike, then I raped her when nobody was watching. My second victim was a little white girl named YYYYYY. She was in the bathroom at a public park. I touched her under her clothes on the leg and between her legs. I stopped when my sister came in and told me to stop. It was never reported to the police. My third victim was a little dark-skinned black girl named ZZZZZZZ. I raped her, but I’m not ready yet to talk about the details of the offense. I am always at risk to re-offend.”

21. Sex Offending Cycle Trigger Pseudo- Guilt/shame Bad Feeling
Cognitive
Distortions
Deviant Fantasy
Reliving thru
Fantasy
Arousal
Planning
Escape
Setting up victim
OFFENSE

22. What is the Pathways model for offense conceptualization?
Offenders do not all offend for the same reasons– there are different cognitive processes and maladaptive coping methods that lead to offense
These cognitive behavioral pathways to re-offense have to do with how offenders self-regulate their behavior (Ward, Hudson, & Keenan, 1998)
First distinction: avoidant (tries to avoid offending) vs. approach (offending is pursued goal)
Model has evolved to include four sub-types of offenders, defined by their offense regulation type.

23. What are the four subtypes of offenders defined by the self-regulation model?
Avoidant passive (under-regulated)– want to avoid offending, but lack coping mechanisms
Avoidant active (mis-regulated)– choose coping methods that work poorly or short term
Approach automatic (under-regulated)– on “autopilot”, move towards high-risk situations and offend opportunistically
Approach explicit (intact regulation)– coping methods support offending, move with planning and intent

24. Does the Pathways model fit for IDD offenders?
Yes, at least as far as we know (Keeling, Rose, & Beech, 2007)
Similar distribution for IDD offenders across the four groups as for non-IDD offenders
Distribution heavily favors Approach pathways for both groups
ID of client-specific offender pathway has a real-life effect on both treatment emphasis and environmental restrictions for IDD offenders.

25. How is assessment different for IDD offenders?
Typically, no comprehensive summary of SO history exists– often necessary to acquire and sort through old documentation for bits and pieces
Once rapport is established, can sometimes be unusually forthcoming with unreported incidents (NOTE– often requires a few vague facts to “prime the pump”)
Mental status exam is critical
Memory problems are a real concern
Few standardized instruments for the population

26. What is the best way to assess re-offense risk?
STATIC-99 is gaining popularity
The original sample included IDD offenders. The 2003 revised Coding Rules specifically indicate that it can be used for “Developmentally Delayed offenders” (pp. 6)
Problem– scoring depends entirely on charges/ convictions/ sanctions by the criminal justice system, and many IDD offenders are not competent.
Solution– use incidents where the behavior was serious enough to have been charged AND the client received some sort of sanction.
“If no sanction is applied to the offender, these offenses are not counted. If the behavior is sufficiently intrusive that it would most likely attract a criminal charge had the behavior occurred in the community and the offender received some form of ‘in-house’ sanction, these offenses would count as offenses on the STATIC-99.” (from the Institutionalized Offenders section of the 2003 STATIC-99 coding rules, pp. 7)

27. STATIC-99 (continued)
Ongoing unsanctioned offending behaviors (exhibitionism, sexual phone calls, etc.) can make it hard to ID an Index Offense
Incompetence to stand trial may mean serious offenses (including child rape) may not have been officially sanctioned (perhaps never even arrested or charged).
Offenses for which the recipient was not sanctioned or punished may not be appropriate for inclusion in scoring.
Incomplete records mean that some serious offenses may not even be listed as a part of a client’s history.
If anything, the STATIC-99 is likely to under-predict re-offense risk for this population.

28. What is the best way to assess progress in treatment?
Treatment Intervention and Progress Scale for Sexual Abusers with Intellectual Disabilities (TIPS-ID) (McGrath, 2005)
Assesses only dynamic (changeable) factors
25 items in seven different treatment areas, Likert-scale permits a scoring range from 0-75
Specifically created for and normed on IDD offenders, can be used every 6 months
New instrument (2005), small normative sample (n=87), bare-bones scoring

29. What are the ethical concerns around confidentiality?
Explain the limits on confidentiality during the assessment and again at intake– IDD recipients benefit from repetition
Explain in a way that the recipient can understand. Have them repeat back what you said in order to check comprehension (recipients will sometimes nod, even if they do not understand).
Will have to explain all over again to the recipient’s conservator (legal guardian), if they have one.
Obtain releases to share information between all treatment team members (i.e., probation officer, judge, provider agency, ISC, psychiatrist, nurse, etc.). Call early and often.
Group—“whatever happens in here, stays in here—but if there is something I think your staff needs to know, I’m going to tell them”
Provider staff should be warned about offender attempts at “secret keeping”—if recipient tries to insist, refer to the clinical team
Individual and group therapy notes may be kept in a separate file from other DMRS charts/documentation for the recipient– minimizes the temptation to “browse through” sensitive treatment notes.

30. What is RHD Mainstay Memphis?
Transplanted model from a successful agency in Philadelphia (operating since 1999)— five-site multi-disciplinary consortium provides regular consultative support, along with support and oversight from the parent corporation
Supported living program (homes or apartments in the community with 24 hour staff), small size (10 people max)
On-site integrated clinical staff for maximum residential staff support (weekly meetings with all SO staff)
Recipients participate in weekly individual therapy, Social Skills Group, and SO Treatment Group
Extensive and ongoing training for all staff
Crystal-clear communication and consultation pathways
Both programmatic and individualized restrictions that have been OK’d and are continually overseen by the Human Rights Committee

31. What is the RHD Nashville Respite/Transition program?
Behavioral respite with SO services overlay
Most residents are stepping down from a higher level of care, taking a “test run” with extensive support before moving to a community SL provider
Single building, eight recipients housed on two different “pods”, most recipients have SO histories
4-6 direct care staff 24/7, plus on-site management team & clinical staff (1:1 staffing minimum for community trips)
Recipients under similar restrictions to the Memphis program, staff receive similar specialized training
All recipients receive daily group therapy on various topics (social skills, community living, etc.)
SO recipients also attend a weekly SO treatment group and have access to individual therapy

32. What are the assumptions underlying the programs?
Lifetime supervision model
Relapse risk is most effectively reduced through clinical treatment, intensive supervision (based on individual need), and recipient accountability
Community safety must sometimes take precedence over personal freedom
Improvement is possible for non-SO issues
Improvement is possible for SO issues (i.e., increased responsibility for offending behaviors, participation in relapse prevention, etc.)
Overall goal is increasing progress towards self-management
Movement towards healthy sexuality is possible, but the process will be driven by a recipient’s individual abilities and needs.

33. How is working with SO DMRS recipients the same as working with non-SO recipients?
Same expectations for recipient care by the state
Same DMRS audit and oversight procedures (TEA, etc.,)
Same basic state–mandated training package
Process for reportable incidents, investigations, and AOD is the same
Same money (must work within the fee structure already in existence) (LON 6)
Same access to a higher level of care—police, mobile crisis, behavioral respite, hospitalization

34. How is day-to-day service delivery different in the RHD programs?
Sex offender status is discussed openly within the program
Sexual behaviors are discussed openly
Staff’s role as a protector of the community strongly emphasized
Inappropriate sexual behaviors are immediately addressed by both staff and other recipients
Staff receive ongoing consultation and support around coping with sexual issues
Direct care staff considered an active part of SO treatment intervention strategy (SO treatment also happens outside the therapist’s office)
Recipients are encouraged to hold each other accountable for their SO related decisions and behavior, and to take an active part in their own relapse prevention
Social support between SO recipients is encouraged, with appropriate supervision
More extensive discussion of potential community participation activities and employment settings
Consistent team communication to reduce risk of triangulation

35. What does recipient supervision look like on a day-to-day basis?
Shift in emphasis—the traditional model is 80% individual safety, 20% community safety
RHD model—50% individual safety, 50% community safety
Primary staff concern is less about limiting choice and more about preventing an imminent harm situation from occurring
Preventing an offense IS protecting the recipient—protecting them from retaliatory aggression, criminal justice involvement, or a return to a more restrictive setting (hospital)
All SL recipients are LON 6, two staff available at all times
Staff monitor ALL social interactions (with other staff, peers, family, adults in the community) and prevent interactions with children or vulnerable adults
Staff always on the lookout for potential SO triggers in the environment (i.e., moving recipients back away from the windows when its time for school to let out). Direct care staff enlisted as “clinical observers”, who actively gather info for clinical team about internal and external triggers, deviant fantasy, and sexual behaviors.

36. What sort of training and support do staff receive?
All regular DMRS mandated trainings
SO Basic training—all day training, required for staff who are going to work in our SO homes. Also offered to ISCs, POs, BAs, etc. free of charge
SO Booster training—two-hour training, required every six months for all staff in SO homes (sometimes more frequently, if there has been an incident or a progressive discipline issue). Content is the same as the SO Basic, just more compressed and with a different emphasis
SO Pre-group—group session for staff of all SO houses, held weekly, run as a peer supervision group
On-site consultation—regular house visits by Project Director, clinician, and RSM.

37. How can agency structure limit opportunities to re-offend?
Model: Small size coupled with frequent opportunities for information exchange and collaborative organizational structure—different staff positions/roles are integrated and complementary rather than separate
Frequent communication and cohesive staff collaboration helps to close the “gaps” that offenders may try to exploit
Provides consistent rules, behavioral expectations, and messages from all staff
Restrictions necessary for safe community integration are understood by recipients and authorized/supported by management—maximizes chance that line staff will implement restrictions (i.e., management takes the heat)
Supports immediate but caring confrontation of inappropriate behaviors by both staff AND peers
Multiple opportunities for staff support (both technical and emotional) increases cohesiveness among staff and buy-in to the model
Limits grooming opportunities by consolidating the reporting of rare events (i.e., the whole staff gets the whole story)
Increases coordination of care with outside agencies (psychologist collaborates with PO about implementing restrictions and court orders then communicates info to line staff, nurse follows up medication issues with psychiatrist, reports back immediately to the larger group, etc.)

38. How do we cope with potentially traumatic incidents (for recipients and/or staff)?
First response—follow all regular DMRS and RHD Mainstay Memphis procedures (i.e., ensure safety, medical attention, AOD, reporting to investigators, incident reports, etc.)
Acute incidents (staff): receive outside EAP referral for a critical incident Debriefing (done hours after the event, either on the job site or in the therapist’s office, staff’s choice)
Chronic stress (staff): Helping Hands—RHD EAP program that offers 10 sessions of free therapy, no strings attached
Pregroup meeting also helps staff process feelings
Acute incidents (recipients): Debriefing done by clinical team member (24-48 hours)
Chronic stress (recipients): already in therapy, may look at programmatic changes (i.e., altering peer’s behavior plan, changing residences, etc.)
Management team response to perpetrator of the incident
Police involvement? (offender responsibility/staff rights vs. state mandate)

39. Who can you contact for additional help or support?
Division of Mental Retardation Services (DMRS)
(800) ,
Western TN DMRS Sexual Behavior Risk Reduction Committee (SBRRC):
Dr. Tucker Johnson (901) ,
RHD Mainstay Memphis (consultation for a fee):
Dr. Michael Gavetti, (901) ,