Ronald J. Ricci, Ph.D. Cheryl A. Clayton, L.C.S.W. Trauma Informed Sex Offense Specific Treatment An approach to CBT-RP Treatment Ronald J. Ricci, Ph.D. Cheryl A. Clayton, L.C.S.W.

Agenda: Current state of the field Emerging theories of sexual offending (What they offer. What they don’t) The knitting of these theories into an approach to treatment The missing piece The specific treatment components of the expanded model

Before We Start….a word about roles. The Containment Model Probation Treatment Polygraph The Probation/Parole Officer (taken from C.S.O.M.) The probation/parole officer is the leader of the supervision team. The representative of the criminal justice system The primary enforcer of conditions imposed by the court and is empowered to use the coercive power of the criminal justice system Responsible for making recommendations to the court based on the information provided by treatment providers and polygraph examiners Ensure the safety of past and potential victims by restricting offenders' activities respond to inappropriate behavior with appropriate controls and sanctions, and reward progress when appropriate. Manages and convenes the multidisciplinary supervision team Play a very active role in keeping the team together and functioning in a collaborative and mutually beneficial way. The Treatment Provider Work to create internal controls within the mindset of the offender. Provide information about treatment progress that may affect the supervision plan May modify the treatment plan based on information from supervision agents or polygraph exams. Help other members of the supervision team understand the offense so the overall supervision can better protect victims and potential victims. Help sex offenders develop coping skills regarding the constraints of supervision and learn how to handle stress and anger appropriately. Teach offenders self-management approaches, such as relapse prevention, that help them understand and recognize the triggers that are precursors to offending behavior. Help offenders develop victim empathy (which may lessen the likelihood of a re-offense), Work with offenders to manage and reduce deviant arousal patterns Reward progress toward treatment goals. Help educate family members and other associates of the offender about sex offender behavior.

Sex Offense Specific Treatment Standard Treatment is Cognitive Behavioral Relapse Prevention (CBT-RP) Treatment Primary structure for 90+% of sexual offender treatment programs (McGrath, Cummings, & Holt, 2003). A meta-analysis of 42 treatment studies (9,454 participants) showed 12.4% recidivism for treated offenders versus 16.8% for untreated (Hanson, Gordon, Harris, Marques, Murphy, & Quinsey, et al. (2002). Recent study explored the effectiveness of intensive RP treatment on sexual re-offense. The final conclusion was that their findings “generally do not support the efficacy of the RP model” (Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005, p. 79). NOTE: we are not only talking about effectiveness, but also about treatment length. Point out that the SOTEP was just RP

…the project did not give offenders enough motivation to change and did not allow for all relevant treatment targets to be addressed. Marques, J.D., Wiederanders, M., Day, D.M., Nelson, C., & van Ommeren, A. (2005). Effects of a relapse prevention program on sexual recidivism: Final results from California’s Sex Offender Treatment and Evaluation Project (SOTEP). Sexual Abuse: A Journal of Research & Treatment, 17, 79-107.

Reconsidering CBT-RP Treatment The treatment methods evaluated were inaugurated two decades ago Largely a one-size-fits-all model The more recent Self-Regulation Model emphasizes the etiology of sexual offending behavior including childhood sexual trauma (Ward and Siegert, 2002) Can we add developmental adversity here?

Some missing pieces with Standard CBT-RP Treatment Motivation (beyond fear) for clients to engage in the treatment process Therapeutic rapport with clients Safe environment in which to do emotionally difficult work Resolution of factors contributing to offending problem Considering what to approach in addition to what to avoid

Observations… Despite everyone’s best effort, sometimes there were inexplicable barriers to treatment engagement Despite apparently letter-perfect work, sometimes clients kept making the same bad choices repeatedly, or kept tripping over the same issues I just can’t feel what I know I should feel I just can’t do what I know I should do I hear what you’re saying, and I know it’s right, but I just don’t believe it

A Further Observation Clients with childhood sexual abuse (CSA) often times demonstrate lack of trust, intimacy deficits, emotional constriction, and implicit beliefs about themselves and/or their victims that impede treatment progress and contribute to re-offense risk NOTE; Vulnerability factors are not limited to sexual origins – may include neglect, abandonment, etc. Adverse childhood experiences can plant seeds for defenses including, but not limited to cognitive distortions,

Program Philosophy Community Safety Individualized Consider client readiness Collaborative and Structured Insight oriented Based in relationship (treatment, group, inner and outer circle) Systemic Therapeutic relationship is shown to account for 80 % of change in clients.

Procedure Ten sexual offenders in a CBT-RP treatment program with reported histories of child sexual abuse were selected to undergo EMDR trauma treatment as a adjunct to their standard CBT-RP program Pre-treatment TSI, SOTRS, and PPG measures were obtained An average of six EMDR sessions using standardized protocols (Shapiro, 2001) were conducted with the 10 EMDR-added treatment group clients. EMDR treatment was considered complete when participants reported an SUD as low as they expected their disturbance could become Post-treatment TSI, SOTRS, and PPG data were obtained for the EMDR-added treatment group. Follow up data were obtained from 8 of the 10 participants PPG data were obtained from the remaining child molesters in the same treatment program to serve as a control Clarify that it wasn’t a controlled study, We did the control group after seeing the PPG outcome.

Hypothesis Unresolved CSA inhibits full treatment engagement resulting in reduced internalization of important treatment concepts Adding trauma resolution to standard CBT-RP treatment will: Increase motivation for treatment Improve treatment engagement Increase victim empathy Facilitate internalization of treatment concepts

Results All six subscales of the Sex Offender Treatment Rating Scale (SOTRS) showed significant pre-post EMDR improvement Insight, Sexual Thoughts, Risk Awareness, Motivation, Empathy, Disclosure

Other Findings Reduction in deviant sexual arousal to age and gender of victim(s) of conviction as measured by Phallometry These reductions were maintained at 6 and 12 month month follow-up

Phallometry Results

Qualitative Results Recognition of Contributors to Distorted Beliefs “I think what he done to me made me think it’s okay to have sex with younger people as long as you don’t force them. As long as they say ‘okay’.” Increased Participation in Group Therapy “..it changed how I feel about myself and kind of raising my head up and that I am a good person and do have good things to offer in group, and to other people too.” Increased Empathy “I can, I can feel the hurt of my own victimization, as well as my victim.” Clarification of Thoughts “It used to be like, like my mind was like a plate of spaghetti. I’d look at it, and it was all mixed up, twisted. Now my mind, it’s like there’s meat here, and potatoes, and a vegetable over here. It’s like that now.”

Implications Trauma informed Sex Offense Specific Treatment provides the potential for addressing implicit beliefs and deviant arousal contributing to sexual re-offense risk Potential for sustained reduction in deviant sexual arousal responses which has proved difficult to achieve with current treatments Provides potential to enhance CBT-RP treatment given recent evidence of the limited effectiveness of current treatments for sexual offenders

What does a trauma informed approach to therapy add to the treatment process? Motivation Therapeutic rapport Safe environment in which to do emotionally difficult work Resolution of factors contributing to offending problem Considering what to approach in addition to what to avoid

Basic Treatment Structure (expanded treatment model) Sex offense specific Risk & Needs Assessment Objective measures (Polygraph, Penile Plethysmograph) Weekly facilitated peer process group with CBT-RP treatment including affect tolerance and skills training Individualized trauma treatment at relevant points Support involvement with focus on accountability, communication, and relationship Collaborative approach (Probation, treatment, client, support system, polygraph)

Treatment Theories The overarching program model and the specific treatment components consider: Trans-theoretical Change Model; Risk, Needs, Responsivity Model, Self-Regulation Model, Good Lives Model, and Foundational Issues/Trauma Model So from this we began to consider what approach to sex offense specific treatment would trauma treatment best be couched within?

Prochaska and DiClemente’s Stages of Change Model Stage of Change Characteristics Techniques Pre-contemplation Not currently considering change: "Ignorance is bliss" Validate lack of readiness Clarify: decision is theirs Encourage re-evaluation of current behavior Encourage self-exploration, not action Explain and personalize the risk Contemplation Ambivalent about change: "Sitting on the fence" Not considering change within the next month Encourage evaluation of pros and cons of behavior change Identify and promote new, positive outcome expectations Preparation Some experience with change and are trying to change: "Testing the waters" Planning to act within 1month Identify and assist in problem solving re: obstacles Help patient identify social support Verify that patient has underlying skills for behavior change Encourage small initial steps Action Practicing new behavior for 3-6 months Focus on restructuring cues and social support Bolster self-efficacy for dealing with obstacles Combat feelings of loss and reiterate long-term benefits Maintenance Continued commitment to sustaining new behavior Post-6 months to 5 years Plan for follow-up support Reinforce internal rewards Discuss coping with relapse Lapse Resumption of old behaviors: "Fall from grace" Evaluate trigger for relapse Reassess motivation and barriers Plan stronger coping strategies Pacing

Risk Need Responsivity Approach Andrews & Bonta, 1998 Risk Principle – concerned with matching risk level to treatment dose Need Principle – states treatment should target criminogenic needs Responsivity Principle – concerned with ability to reach and make sense to treatment recipient

Risk Need Responsivity : What It Does Reduce maladaptive behaviors Eliminate distorted beliefs Remove problematic desires Modify offense-supportive emotions and attitudes

Risk – Need: What It Doesn’t Consider contextual factors Consider the relationship between risk factors and human needs or goods Address treatment readiness Focus on therapeutic relationship, therapist factors, offender attitudes This can come out for Charolottesville

Self-Regulation Model of the Relapse Process Ward, T., Hudson, S.M., & Keenan, T. (1998) Ward, T., Hudson, S.M., & Keenan, T. (1998). A self-regulation model of the sexual offense process. Sexual Abuse: A Journal of Research and Treatment, 10, 141-157.

SRM in brief… Contains a number of pathways, representing different combinations of offense-related goals and distinct regulation styles in relation to sexually offense contact. (Ward et al., 2004) Considers: etiological pathways to offending, and once offending problem has developed, what is the particular offending pathway. Ward, T., Bickley, J., Webster, S.D., Fisher, D., Beech, A., & Eldridge, H. (2004). The Self-regulation Model of the Offense and Relapse Process: A Manual: Volume I: Assessment. Victoria, BC: Pacific Psychological Assessment Corporation.

Empirical Support for SRM Bickley, J.A. & Beech, R. (2002). An empirical investigation of the Ward & Hudson self-regulation model of the sexual offense process with child abusers. Journal of Interpersonal Violence, 17, 371-393. Bickley, J.A. & Beech, R. (2003). Implications for treatment of sexual offenders of the Ward and Hudson model of relapse. Sexual Abuse: A Journal of Research and Treatment 15(2), 121-134. Ward, T., Bickley, J., Webster, S.D., Fisher, D., Beech, A., & Eldridge, H.(2004). The Self-regulation Model of the Offense and Relapse Process: A Manual: Volume I: Assessment. Victoria, BC: Pacific Psychological Assessment Corporation. Webster, S.D. (2005). Pathways to sexual offense recidivism following treatment: An examination of the Ward and Hudson self-regulation model of relapse. Journal of Interpersonal Violence, 20, 1175-1196. Yates, P.M., & Kingston, D (in press 2006). Pathways to Sexual Offending: Relationship to Static and Dynamic Risk Among Treated Sexual Offenders, Submitted to Sexual Abuse: A Journal of Research and Treatment. Yates, P.M., Kingston, D., & Hall, K. (2003) Pathways to Sexual Offending: Validity of Hudson and Ward’s (1998) Self-Regulation Model and Relationship to Static and Dynamic Risk Among Treated High Risk Sexual Offenders. Presented at the 22nd Annual Research and Treatment Conference of the Association for the Treatment of Sexual Abusers (ATSA). St. Louis, Missouri: October 2003.

Vulnerability Factors Ward & Siegert 2002 Intimacy & Social Skills Deficits Distorted Sexual Scripts Emotional Dysregulation Offense Supportive Beliefs Any or all of the above PLUS Deviant Sexual Scripts (oftentimes from childhood sexual victimization) These are the etiological pathway factors

SRM – Offense Related Goals Avoidant Approach These are descriptions of the offending pathways

SRM – Regulation Styles Under-regulation Mis-regulation Effective regulation

SRM – The Four Pathways Avoidant – Passive Avoidant – Active Approach – Automatic Approach – Explicit

Summary of Four Pathways SELF-REGULATORY STYLE DESCRIPTION Avoidant-Passive Under-regulation Desire to avoid offending but lacks coping skills to keep it from happening- escape from self-awareness Avoidant-Active Mis-regulation Desire to avoid offending but uses ineffective or counterproductive strategies Approach-Automatic Overlearned sexual scripts, impulsive, poorly planned behavior. (Auto-pilot) Approach-Explicit Effective regulation Desire to sexually offend with effective strategies towards that end

Treatment Targets for Avoidant-Passive Discover goals and vulnerability factors Improve coping (self-regulation) skills Develop goods-seeking strategies Raise awareness of offense process (where was avoidance goal abandoned) Cognitive distortions Social skills Problem-solving skills Meta-Cognition skills

Treatment Targets for Avoidant-Active Discover goals and vulnerability factors Alter coping skills Decision-making skills Raise awareness of offense process (where was avoidance goal derailed) Emotion regulation Cognitive distortions

Treatment Targets For Approach-Automatic Alter the over-learned cognitive & behavioral scripts Resolve foundational issues Alter offense-related goals Victim impact Recondition deviant arousal Emotion regulation

Treatment Targets for Approach-Explicit Examine core schema including view of self, intimacy, and sexuality Create atmosphere conducive to disclosure Alter route to securing human goods Cognitive restructuring External monitoring, supervision, support

SRM: What it Does… Considers etiology that then guides treatment intervention Considers differences in offense styles that then guides treatment goals

SRM: What It Doesn’t… Provide a means of addressing vulnerability factors beyond self-awareness Consider the contextual variables of the therapy This one can come out for Charolottesville

The Good Lives Model of Offender Rehabilitation Ward, T., & Gannon, T. (2006) Ward, T. & Stewart, C.A. (2003) Ward, T., & Gannon, T. (2006). Rehabilitation, etiology, and self-regulation: The Good Lives Model of sexual offender treatment. Aggression and Violent Behavior, 11, 77-94. Ward, T., & Stewart, C.A. (2003). The treatment of sex offenders: Risk management and good lives. Professional Psychology: Research and Practice, 34, 353-360.

GLM Says… Human beings (of which SOs are) are goal directed organisms predisposed to seek a number of primary goods.

GLM believes…. The individual commits criminal offenses because he lacks the opportunities or skills to obtain valued outcomes in socially acceptable ways.

Primary Goods Include… Life (healthy living & functioning) Pleasure Knowledge Excellence in play & work Agency, autonomy, self-directedness Inner peace Friendship, relationship, intimacy Community Spirituality Happiness Creativity

GLM assumes… Core values drive daily activities and lifestyle. Daily activities and lifestyle shape self-perception.

GLM Recommends Obtaining a holistic and broad understanding of offender’s lifestyle leading up to the offending, and using this knowledge to help him develop a more viable and explicit good lives plan.

GLM says Human beings are contextually dependent organisms. Rehabilitation must consider the match between the offender’s characteristics and the environment into which he lives/will live.

In the GLM CRIMINOGENIC NEEDS are internal or external obstacles that frustrate and block the acquisition of primary human goods. Can see how EMDR would aid in addressing these issues.

FOUR Problems that Manifest in Criminogenic Needs or Dynamic Risk Factors Means – used to secure goods may be inappropriate strategies Scope – of goods the offender considers or has access to may be inadequate Conflict – between goods. For example, use of domination to gain autonomy thwarts the good of intimacy Capability – lack of skills or knowledge

GLM- Both/And, not Either/Or Managing risk without concern for goods promotion or well-being could lead to a disengaged and hostile client Simply seeking to increase the well-being of an offender, without regard for his level of risk, may result in a happy but dangerous individual

GLM: What it Does… Addresses treatment motivation Frames offending in non-threatening and accessible context Offers replacement behaviors

GLM: What It Doesn’t… Resolve foundational issues that hamper the ability to develop skills necessary to attain human goods Resolve the developmental issues that contribute to the offense pathways

The Missing Piece A Trauma Informed Lens Through Which To View The Problem

This is not your father’s trauma We came to recognize that other trauma related issues often surface and are resolved in the process of trauma treatment. The etiology of the offending problem often involves issues other than sexual abuse. Other issues interfering with the ability to form intimate peer relationships (e.g., loss, rejection, attachment ruptures, physical and emotional abuse) came to light as relevant in the trauma processing. These are what we recognize as dynamic risk factors. Understanding and resolving the origins increases the chances of improved treatment engagement AND sustained treatment effects.

Trauma Informed Lens Adaptive Information Processing F. Shapiro The approach is to view clients through the lens of looking for etiological issues at the beginning and throughout the treatment process and recognize that dysfunctionally stored memories from childhood/adolescence set the stage for future behavior and can push problematic behavior in adulthood. We look for the implicit beliefs that stem from childhood events including beliefs about the world in general as well as views of self and others that contribute to dynamic risk factors. These issues can potentially be resolved as we assist clients in clarifying them. As a by-product, clients often come to recognize a connection to their sexual offending which furthers their motivation to address them throughout the treatment process. It has much to do with the way we view our client’s problem.

Stages of Treatment

Why Am I Sitting Here? Pre-contemplation stage of change Offense introduction Do NOT coach or you will create a Parrot Tag subtle distortions, minimizations, etc. aloud and predict clarity in future

Pacing & Leading Attacking a client’s position, particularly prior to establishing a working therapeutic relationship, is likely to damage sense of self, impede trust-building, and entrench the client’s negative position. Aggressive treatment approaches markedly decrease the chances that the sexual offender will attain treatment goals. (W.L. Marshal et al. 2002) TALKING POINT: Shame versus Guilt Marshall, W.L., Serran, G.A., Moulden, H., Mulloy, R., Fernandez, Y.M., Mann, R.E. et al. (2002). Therapist features in sexual offender treatment: Their reliable identification and influence on behavior change. Clinical Psychology and Psychotherapy, 9, 395-405.

Pacing & Leading (con’t) Having the offender "parrot" a list of risk avoidant techniques (that internally he believes has nothing to do with him) results in a client that looks and sounds safe, but that will likely choose not to be safe when out from under the watchful eye of containment. Attempts to reduce deviant arousal prematurely, while cognitive distortions remain (“part of her really did like it”; “he's doing fine, it didn't really affect him as they say”), is destined for failure.

Pacing & Leading (cont’d) The pacing of treatment is important. For example, Ward, Yates & Long (2006, p. 76) caution that “self efficacy should not be enhanced until offense-avoidance skills are effectively developed and have become part of the individuals repertoire and regular functioning. This is because an increase in efficacy expectations without the development of concomitant skills can place the individual at higher risk to re-offend.”

What Is This Problem Called Sexual Offending? Pre-Contemplative or Contemplative Stage of Change Non-threatening education about the problem Personalize concepts as ready Do not create an us-them dynamic Importance of Pacing & Leading

Psycho-Education Topics Woven in to Process Group (as needed) Health Communication Assertiveness Training Anger/Behavior Management Stress Management Cognitive Restructuring Healthy Sexuality Empathic Interaction Sexual Reconditioning Relapse Prevention

How Does The Problem Relate to Me? Moving from Contemplation to Preparation and Action Stages of Change Message: The group wants to collaborate with the client to help him figure out his problem

Full Offense History Disclosure Polygraph Expectation from beginning is that full disclosure is important Preparation is done with group support Less than perfect offense introduction is tolerated, flagged aloud for future intervention Not everyone will be here at this point In a recent article, "Denial predicts recidivism for some sexual offenders," Nunes et al. (2007), with Hanson as second author, described two studies that included 1000 adult sexual offenders in which, "contrary to expectations," denial was associated with increased sexual recidivism among both low-risk offenders and incest offenders, and replicated in two independent samples. Nunes, K L., Hanson, R. K., Firestone, P., Moulden, H. M., Greenberg, D. M., & Bradford, J. M. (2007). Denial predicts recidivism for some sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 19, 91-105. Langton et al. (2008) described both minimization and denial in adult sexual offenders as significant predictors of sexual recidivism, with minimization as a significant predictor among high risk offenders (in contrast to the finding of Nunes et al.). In their study of 436 sexual offenders, they report that denial was associated with serious (including sexual) recidivism, and conclude that is reasonable to postulate that the presence of denial and minimization, specifically during and at the conclusion of treatment, represents "an increased risk among higher risk offenders for sexual recidivism" (p. 91). Langton, C. M., Barbaree, H. E., Harkins, L., Arenovich, T., McNamee, J., Peacock, E. J., et al. (2008). Denial and minimization among sexual offenders: Posttreatment presentation and association with sexual recidivism. Criminal Justice and Behavior, 35, 69-98. Levenson and Macgowan (2004) found that treatment progress was correlated with lower levels of denial, and that engagement in treatment and denial were negatively associated with one other. Levenson. J. S., &. Macgowan, M. J. (2004). Engagement, denial, and treatment progress among sex offenders in group therapy. Sexual Abuse: A Journal of Research and Treatment, 16, 49-63.

Life History-Sexual Development What clients are encouraged to look at here are dependent upon their identified offending pathway Allows for the establishing therapeutic rapport Allows for connection between clients Identification of vulnerability factors and trauma targets

Life / Sexual Development History – Avoidant Passive Pathway Avoidant-Passive offenders are encouraged to look at life history with an eye towards understanding key experiences and events that impact present level of functioning. Naturally, the client’s life choices and current behaviors are selections he makes based on his core beliefs, shaped through the lens of his view of the world. These, then, can be examined in relation to the human goods he was seeking through his offense-related behaviors. For example, early experiences may have left him vulnerable to feelings of abandonment, and ill-equipped to manage those feelings when they arise. This may create a core belief that he is unworthy of relationships which, coupled with his innate need for intimacy, may lead him to seek intimacy with someone who is non-judgmental, less-threatening, and easier to impress, such as a child.

Life / Sexual Development History – Avoidant Active Pathway Avoidant-Active offenders are encouraged to look for life experiences that make them ‘vulnerable’ to offending. There is a relationship between life events, dynamic risk factors, and the client’s search to achieve primary human goods. The client is looking back, therefore, for life events that shaped his core beliefs in such a way that his efforts to obtain human goods took the form of offense-related behaviors. They may also discover origins of adherence to ineffective strategies that result in goal failure (i.e., avoiding offense-related behaviors).

Life / Sexual Development History – Approach Automatic Pathway Approach-Automatic offenders are looking for life experiences that fostered and entrenched long-standing scripts from which they ‘automatically’ respond to situational cues. Some cognitive scripts evident in these types of offenders include a sense of entitlement (including sexual entitlement), hostile attitudes, stereotyped beliefs, suspiciousness, and distorted beliefs about children/females, child development, etc.

Life / Sexual Development History – Approach Explicit Pathway Approach-Explicit offenders are looking for origins of well-entrenched offense-supportive attitudes. He may also be able to discover origins of entitlement, or desires for retribution. As he identifies the meaning of these early experiences to his offending, he also comes to see that he was attempting to achieve life goals/human goods, and is more open to looking at other, pro-social ways he might be able to achieve those goods/needs.

Trauma Treatment Trauma Treatment is done at this point to target those memories identified as contributing to development of offending problem (attachment issues, intimacy deficits, physical, emotional, sexual abuse). Those issues consistent with the Self-Regulation Model etiological pathways.

Final Form of Offense Introduction A complete and distortion-free offense introduction Respectful language Do not include legal consequences Collaboratively identify offense pathway and tailor treatment plan accordingly Non-deceptive full disclosure polygraph

Sexual Offense Histories Include all novel pathways Refine pathway analysis Extract distortions, rationalizations, etc. (the grease that moves the wheel) Lays groundwork for offense pattern NOTE; offense pathways can change over time

The Problem Tends to be Cyclical Clarify awareness of risk of future offending If I reengage in problematic behaviors identified in treatment my risk to sexually re-offend is increasing

Sexual Reconditioning For those with documented deviant arousal only Do not attempt until all evidence of cognitive distortions eliminated

What Is The Cyclical Nature of MY Problem? Vulnerability Factors Triggers, Stressors, Motivators Maladaptive Coping Skills Selections, Planning, Grooming, etc. Post-Offense Evaluation

Trauma Treatment Trauma Treatment done here on those issues that clients and clinicians note client continues to “trip” over. These are typically the issues triggering the beginnings of offense pattern (feelings of abandonment, overwhelming need to please others, feeling used, etc.)

How Can I Avoid Doing This Again? Predicted pattern of offending Contributing, Vulnerability, and Risk factors Personal Values, Human Goods, Primary Goods, Needs

Contextual – Systemic Approach Community support person(s) as treatment partner Human beings are interactive and live in context Plans must realistically match environment

Relapse Prevention-Good Life Internal Triggers & Responses External Triggers & Responses Achievement of Human Goods Typically a recounting of the life they have been living as treatment has progressed

Practice Practice

Phase-Out If probation supervision remaining after treatment completion, client develops a plan to phase out of weekly treatment attendance.

What does a trauma informed approach to therapy add to the treatment process?

Related Publications Ricci, R.J., & Clayton, C.A. (in press May 2009). EMDR with sex offenders in treatment. In R. Shapiro (Ed.) EMDR Solutions II for depression, eating, performance, and more. Norton. Ricci, R. J., & Clayton, C.A. (2008). Trauma resolution treatment as an adjunct to standard treatment for child molesters. Journal of EMDR Practice and Research, 2(1); 42-51. Ricci, R. J., Clayton, C.A., & Shapiro, F. (2006). Some effects of EMDR on previously abused child molesters: Theoretical reviews and preliminary findings. The Journal of Forensic Psychiatry & Psychology, 17(4); 538-562. Ricci, R.J. (2006) Trauma resolution using EMDR with an incestuous sex offender: An instrumental case study. Clinical Case Studies, 5(3), 248-265.