A HOLISTIC & INTEGRATED MULTI- DIMENSIONAL APPROACH TO RESIDENTIAL TREATMENT FOR YOUTH WHO HAVE CAUSED SEXUAL HARM New York ATSA, Turning Stone 2011 Howard B. Adler, LCSW Harmony Ayers-Friedlander, LMHC Hillside Family of Agencies (

To provide exceptional services based upon best practice and evidence-based research dedicated to:  Stopping sexually harmful behavior  Healing and strengthening the lives of children and families  Creating safer communities for everyone Specialized Care Services Mission

 To be the leader in translating research into effective practice solutions for youth who have caused sexual harm. Specialized Services Strategic Intent

Whom do we serve?  12 – 18 year old boys and their families  History of sexually harmful behavior  Youth non-adjudicated or adjudicated  IQ of 65 and higher Hillside Children’s Center, Varick Campus, Specialized Program, Romulus, NY – 32 Beds Snell Farm Children’s Center, Bath, NY - 28 Beds

Youth & Family Challenges  Trauma history  Self-regulation difficulties  Co-morbid diagnoses  Learning disabilities  Impairments with school and social functioning  Poverty

The rapid advances in the study of sexually abusive youth, although well meaning and praiseworthy, has often narrowed our focus to elusive sexual aspects at the expense of a full accounting of the youth's development and ecology. While there is much in youthful development to distract us from a clear understanding of potential re-offense processes, we can no longer allow adult programming to be the sole source of assessing and treating young people. Robert Longo & David Prescott (Current Perspectives, 2006)

Youth Outcomes Include:  Eliminate or significantly reduce risk of harmful sexual behaviors  Increase protective factors  Reduce trauma symptoms  Eliminate or significantly reduce aggressive behaviors  Increase life skills  Achieve service plan goals and objectives  Connect to three significant people to support ongoing development  Improve academic performance  Increase knowledge of sexual health  Discharged to lower level of care

Family Outcomes Include:  Develop and achieve service plan goals  Commitment to proactive safety plan  Gain access to community resources  Increase coping skills and affect regulation  Increase protective factors  Restore relationships and hierarchy of roles  Increase knowledge of sexual health

In summary, moving the Adolescent Sex Offender treatment field in the direction of Evidenced Based Practice may require rethinking several aspects of business as usual. First, it should involve an honest appraisal of the level of evidence we have for the effectiveness of our established and routine clinical practices. It should involve coming to terms with the fact that, currently, the best supported practice model is radically different in its assumptions, theory and approach from our established and routine clinical practices. Mark Chaffin (Current Perspectives, 2006)

Program Foundation: Empirically Based Best Practices  Eight Elements That Influence Optimum Child Development (The National Research Council and Institute of Medicine (2002) Physical and psychological safety)  Best Practices of Youth Violence Prevention (The United States Department of Health and Human Services, Center For Disease Control, 2002)  Four Factors That Influence Successful Outcomes In Psychotherapy (Miller, Hubble & Duncan, 1999)  Attributes Of Resiliency (Mary Pipher, 2002)

Empirically Based Interventions  Positive Behavioral Interventions and Supports [PBIS] (Sugai et al)  Trauma Focused – Cognitive Behavior Therapy [TF- CBT] (Cohen, Mannarino, & Deblinger)  Aggression Replacement Training [ART] (Goldstein)  Motivational Interviewing (Miller & Rollnick)  Dialectical Behavioral Therapy [DBT] (Linehan)

Retributive: vs. Authoritarian Rigid protocol Imposed “Break denial” Deficit focused Restorative: Facilitative Self-determined pace Collaborative Empower strengths Celebrate milestones A Collaborative Approach for Treatment

The New Milieu  Physical & Psychological Safety  High warmth, low criticism  Trauma sensitive environment  Highly collaborative  Welcoming to families  Mentoring  Learning Environment  Humor, joy and fun

Applied Behavior Analysis Positive Behavior Intervention and Supports  Creating positive school and living environments  Using abundant praise and positive reinforcement for useful skills and socially appropriate behaviors.  Using clear objective data to inform goal development and progress.  A scientific approach to understanding behavior and how it is affected by the environment

TREATMENT PHILOSOPHY Healing occurs within the context of relationships. All services are intended to Instill Hope and are:

Clinical Evaluations  Bio-Psycho-Sexual Eval (Specialized Care Services Evaluation)  Values, Beliefs& Attitudes about Sexuality  Adolescent Sexual Behavior Inventories (Self & Parent)  JSOAP-II  Psychological Assessment  Millon Adolescent Clinical Inventory; Resiliency Scales for Adolescents; Trauma Symptom Checklist for Children; etc.  Psychiatric Assessment

Treatment Approach Clinical programming includes:  Individual therapy  Trauma Outcome Process (T.O.P. *Workbook)  Family therapy  Group modalities: sexual health, life skills, affect regulation, A.R.T.  Multi sensory modalities: art, pet, music, movement, drama, and recreation therapy

Treatment Process Adapted from Resources for Resolving Violence, Inc. (Joann Schladale)

Making Connections It’s about welcoming, orienting, joining, & evaluating youth & family The following is excerpts from a letter of Support demonstrating the power of warm and empathic beginning. To whom it may concern: I am writing to you in reference to Snell Farm and how my family feels about this agency……... I wanted a place that could help my son. The staff there didn’t know me from Adam, all they knew was the needs of my family and what I was looking for. They listened and took time with me before being paid to help. The compassion and kindness that was bestowed to me as a stranger I couldn’t express correctly in words. …….. This time in our lives is a struggle and a battle for my family to get through but for the first time in a long time, I don’t feel like we are going through it alone. I feel like Snell Farm is there with us………..

Family Driven Practice Family Group Decision Making (American Humane Association):  Engaging and calling together a family group  Including family that may not be currently connected and/or has been marginalized.  Empower families to make decisions and plan for youth to create safer communities Another example is Child and Family Teams (CFT)

FAMILY FINDING (Kevin Campbell)  Youth have 40 family members identified.  Functional family members come together, take responsibility, and develop realistic plans for the youth’s safety and wellbeing.  Youth are placed permanently with family, whenever possible.  Learning their family story mends youth’s sense of disconnectedness.  Youth have a high likelihood of permanency and wellbeing now and into adulthood. A six-step model that establishes a lifetime network for disconnected youth:

Recognizing the Need for Help T.O.P. Workbook* Chapter 1 helps kids begin to think about how getting into trouble is negatively impacting their lives, dreams, and goals. Questions help kids consider the need for changing their current behaviors through recognizing things are not working well now but through attention and practice this can change. It’s about taking responsibility through strength and courage.

Perhaps more importantly, this research can lead us to viewing our clients' trauma histories and attachment relationships as essential elements in treating abusive behavior and developing pro-active, preventive interventions that focus on addressing trauma experiences and attachment disruptions in young children. Kevin Creeden (Current Perspectives, 2006)

Working Through Difficult Things that Happen in Life It’s about honestly facing trauma that helps stop harmful behavior.

Working Through Difficult Things that Happen in Life It’s about honestly facing trauma that helps stop harmful behavior.

Working Through Difficult Things that Happen in Life It’s about honestly facing trauma that helps stop harmful behavior.

Trauma Focused – Cognitive Behavioral Therapy I.Psycho-education II.Relaxation skills III.Feelings Identification IV.Cognitive Restructuring V.In vivo Desensitization VI.Parenting Skills VII.Safety Planning

Stopping Harmful Behavior It’s learning that events, thoughts, feelings and beliefs effect behavior. Context: What situations trigger thoughts of violence and abuse? What do I think about myself & others at these times? How do I start to think about causing harm in these situations? What can I do to tame thoughts about destructive behavior in these situations? Victim Selection: Who did I think about harming? What did they look like & what other qualities do they have? What did I imagine them to be like? What were my fantasies about them? What can I do to tame selection of potential victims? The Set Up & Harmful Behavior How many people have I harmed through violence or sexual abuse? What were their names, ages, and relationship to me? How did I gather information about the people I chose to abuse? How did I begin the offense? What can I do to stop setting up others as potential victims? What did I think, and say to myself, as I was-causing harm or abusing? What was the actual sequence of each offense? What were the details of each separate offense? How was the victim reacting to the offense? What did I think and feel when it was over? What am I doing to stop myself from behaving destructively? Self-Intervention & Social Support What specifically am I doing to stop being abusive? What specifically am I doing to manage pain without causing harm? What fantasies do I have that are not abusive? Who might I ask for help in resigning from my abusive lifestyle? How might they be helpful? What situations should I tell them about that are difficult for me? What changes will they notice that indicate I am eliminating my pattern of abuse?

Stopping Harmful Behavior Demon Picture of the shame and guilt as a demon holding him captive. This was a cathartic process as he was able to release his shame and confront the image. Letting Go Created directly following demon drawing. Center image is of a woman sharing or receiving a gift of light, surrounded by images of loving / caring interactions. Illustrates and confirms change in understanding and being. It’s learning that events, thoughts, feelings and beliefs effect behavior.

The following are excerpts from a letter to child who was harmed by sexual abuse Restoring and Building Relationships Hi Jamie, This is your meeting and I can leave whenever you need me to if you don’t like what I’m saying or it’s too hard to hear. I know it’s been a long time since we’ve seen each other. I’m very glad that this day has come. Thank you for allowing me this opportunity to talk with you. What I did to you was not your fault. I take all the blame and responsibility for what happened because it was my fault. You didn’t do anything wrong. The reason why our family was separated was because of what I did and had nothing to do with anything you did………. ……….. I lost your trust by sexually abusing you, and you might not like me or believe in me anymore and I can understand why you would feel that way. You might not want to be alone with me anymore either and that’s ok too. You may not want to be alone with guys because you might be afraid it would happen again or you might not trust them, and I am sorry for that. My family might not trust me now either, and I know I have to regain their trust back and repair what I have done. It’s about making amends, improving relationships and planning for safety & success.

Creating a sand mandala as a form of expressive therapy, brought two conflicted brothers into a more healthy relationship with each other. The process of being in a circle gave them permission to just be together in a natural way that disregarded old barriers. It was a highly intimate in the moment experience, where they allowed each other to be. Restoring and Building Relationships ( Continued)

Living Your Plan Two players having a conversation about the “What Ifs” after treatment. Player one: asking, “Will I move on with my life after treatment. Will I be the same, will I change?” Player two: responds, “You need to move on and not hold on to anger about family. Need to let things go.” “I am going to promise to treat family a lot better than they treated me.” It’s about practicing new ways of responding & living what was learned.

Planning for Continued Success Getting ready to leave soon, this youth created a "healthy place" as he saw it, including another house he joined with his own, where his friends would live. He also built a "stone garden and path" and "lemonade" sign, the side of the house includes the images of his family……. One of this child's strengths were his positive relationships with his same-aged peers. He also liked the outdoors and as he transitioned home the old friends he had in his neighborhood/ those relationships were important in grounding him in health and appropriate socialization…… It’s about demonstrating what was learned through ritual & ceremony.

Aftercare Services It’s about ending and transitioning back to the community with continued help and support

Training & Consultation  Specialized Care Model  Life skills  Aggression Replacement Training  Mentoring  TF-CBT  Family therapy  Family Meetings (Family Driven)  Family Finding  Applied Behavior Analysis  Interactive Supervision

If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be. Johann Wolfgang von Goethe