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 stateNo comprehensive information files for recipientsDirect care staff sometimes reluctant to document sexual behaviorsPolice reluctant to arrest recipients who have DMRS servicesCourts 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 plansFamily/advocates attempt to soften/delete historical information to limit biasInformation “lost” to facilitate referral/transition processEven 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 offendersMost 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 populationLack 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 populationsFear 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 agencyHelping client families who may be in denialAssisting 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 recipientsProviders sometimes tempted to compromise structure in the face of family pressure24/7 staffing, high employee turnover– high risk for miscommunication between shiftsSignificant limits to what can be “imposed” on recipients without their permissionSystem is ISP driven
12 What type of structure should SO Tx providers be facilitating/advocating? Highly structured & consistent environmentTrained staff with clear communication systemsIntegrated treatment services (both for SO and non-SO issues)Consistently enforced restrictions that maximize both safety and appropriate choiceClose 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 preventionSexual reconditioning (to alter deviant arousal patterns)Victim impact/empathy
15 Clinical Treatment Differences (Ability) Literacy problemsLimited memoryDifficulties with abstract reasoningEmpathy and cognitive development (Kohlberg, Piaget, Erikson, etc.)
16 Clinical Treatment Differences (History) Sometimes sheltered from consequences of their actionsSexual education deficitsLong histories of institutionalizationFew 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 supportsLimitless unstructured free timeLimited financesSocial skills deficitsNaive perceptions of complex relationshipsGeneralized 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 slowerDuration of treatment is longerGreater emphasis on repetition and psycho-educationProgress occurs in smaller incrementsEmotional work more basic (often starts with emotional identification)Multi-step interventions often impracticalHomework often difficult to implementReal-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 ISPGather information in detailed SO history (usually requires in-depth review of documentation and involves multiple individual sessions), and prep to discuss Hx in groupCreate SO group introduction using the offender’s own words (respectful language only)ID the recipient’s offense pathway
20 Introduction ExampleAn 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 CognitiveDistortionsDeviant FantasyReliving thruFantasyArousalPlanningEscapeSetting up victimOFFENSE
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 offenseThese 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 mechanismsAvoidant active (mis-regulated)– choose coping methods that work poorly or short termApproach automatic (under-regulated)– on “autopilot”, move towards high-risk situations and offend opportunisticallyApproach 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 offendersDistribution heavily favors Approach pathways for both groupsID 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 piecesOnce 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 criticalMemory problems are a real concernFew standardized instruments for the population
26 What is the best way to assess re-offense risk? STATIC-99 is gaining popularityThe 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 OffenseIncompetence 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) factors25 items in seven different treatment areas, Likert-scale permits a scoring range from 0-75Specifically created for and normed on IDD offenders, can be used every 6 monthsNew 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 repetitionExplain 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 teamIndividual 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 corporationSupported 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 GroupExtensive and ongoing training for all staffCrystal-clear communication and consultation pathwaysBoth 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 overlayMost residents are stepping down from a higher level of care, taking a “test run” with extensive support before moving to a community SL providerSingle building, eight recipients housed on two different “pods”, most recipients have SO histories4-6 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 trainingAll 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 modelRelapse risk is most effectively reduced through clinical treatment, intensive supervision (based on individual need), and recipient accountabilityCommunity safety must sometimes take precedence over personal freedomImprovement is possible for non-SO issuesImprovement is possible for SO issues (i.e., increased responsibility for offending behaviors, participation in relapse prevention, etc.)Overall goal is increasing progress towards self-managementMovement 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 stateSame DMRS audit and oversight procedures (TEA, etc.,)Same basic state–mandated training packageProcess for reportable incidents, investigations, and AOD is the sameSame 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 programSexual behaviors are discussed openlyStaff’s role as a protector of the community strongly emphasizedInappropriate sexual behaviors are immediately addressed by both staff and other recipientsStaff receive ongoing consultation and support around coping with sexual issuesDirect 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 preventionSocial support between SO recipients is encouraged, with appropriate supervisionMore extensive discussion of potential community participation activities and employment settingsConsistent 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 safetyRHD model—50% individual safety, 50% community safetyPrimary staff concern is less about limiting choice and more about preventing an imminent harm situation from occurringPreventing 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 timesStaff monitor ALL social interactions (with other staff, peers, family, adults in the community) and prevent interactions with children or vulnerable adultsStaff 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 trainingsSO 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 chargeSO 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 emphasisSO Pre-group—group session for staff of all SO houses, held weekly, run as a peer supervision groupOn-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 separateFrequent communication and cohesive staff collaboration helps to close the “gaps” that offenders may try to exploitProvides consistent rules, behavioral expectations, and messages from all staffRestrictions 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 peersMultiple opportunities for staff support (both technical and emotional) increases cohesiveness among staff and buy-in to the modelLimits 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 attachedPregroup meeting also helps staff process feelingsAcute 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 incidentPolice 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) ,