1. Treatment with Adolescents with Sexual Behavior Problems: Helping Families Heal
Liza Simon Roper, ACSW, LCSW, LSOE, LSOTP
Jill Novacek, LCSW, LSOE, LSOTP

2. Learning Objectives Participants will learn:
How to apply a trauma-informed approach to the treatment of adolescents with sexual behavior problems
How to incorporate families in the treatment process and include them as active members of the treatment team
The components of the trauma-informed approach used in the program

3. In 1895 a retired pastor and his wife had two faces show up in their window. They took these children in and opened an orphanage Chicago Baptist Children’s home. Our name has changed a few times in our history settling on the name One Hope United in recent years. Our work has been to protect children and strengthen families. Our Vision is Life without Limits. We are in four states serving children and family through Placement, CBFS, and Child Dev. Have grown to provide services to meet community needs.

4. History of Treating Sexual Behavior Problems
1980’s adult “sex offender” treatment to adults in Kane County, Illinois
Juvenile “Sex Offender” program was developed in 2000
Initial collaboration with Kenosha County Dept. of Children and Family Services (WI) and Kane County (IL) Juvenile Court Services
Lake County Juvenile Court Services (IL) later added

5. Juvenile “Sex Offender” Program
Originally, cognitive behavioral approach
Emphasis on relapse prevention
Group treatment as the primarily treatment modality
The program used Timothy Kahn’s Pathways series of workbooks as its primary curriculum
Treatment Focus:
“clarification” to victim(s) in order to repair the hurt that their behavior had caused
Develop an understanding of their “cycle of offending”
Develop a plan to prevent relapse
Not unlike many other programs…

6. Sexual Behavior Problems
What is a “sexual behavior problem?”
Age inappropriate sexual behavior
Non-consensual sexual behavior
Contact vs. Noncontact Offenses
Contact: fondling, penetration, oral sex
Noncontact: sexting, exposure, voyeurism
Sexual behavior is not always motivated by sexual arousal/interest
i.e. a male acting out against another male does not inherently mean that he is interested in males
Males and females both engage in inappropriate sexual behavior
Males tend to get in trouble/referred for treatment more often than females

7. JSO program goals
90 % of clients who completed the treatment program would achieve 90% of their treatment goals
90% of the clients who completed treatment would have a reduced level of risk

8. Advances in the Field Good Lives Model
Holistic, strengths-based approach to offender rehabilitation, initially an adult offender population
Emphasizes the importance of building capabilities in clients to improve the quality of their lives
Recognizes the importance of the therapeutic relationship
Encouraged a shift from shame to a more positive, supportive therapeutic process
Publishing of the ERASOR (Estimate of Risk of Adolescent Sexual Offense Recidivism, Worling & Curwen, 2001)
Dr. James Worling began to discuss the SAFE-T program in Toronto, Canada as a model for working with these youth
As OHU began to look at and establish the overarching goals of the treatment program and figure out how to evaluate it, the overall shift in the conceptualization and treatment of the population informed how our program began to change and shift

9. Understand behavior vs. Stop behavior
Influences of The Good Lives Model and the SAFE-T Program
Increasing emphasis on:
The system that the client was involved in
The focus on strengths
The holistic approach
The recognition that adolescents are developmentally quite different than adults
Up to this point, many programs, including One Hope United’s, emphasized addressing the behavior and preventing the behavior rather than attempting to understand the behavior in the context of the client’s life experiences, supports, family environment, skill level, relationships, and strengths F

10. Developmental Perspective
Developmental perspective includes:
Brain development
Cognitive development
Social development/Attachment to caregivers
Moral development
Sexual development
Given these factors, adults serve as a
“surrogate frontal lobe”

11. Juveniles vs Adults Biological Development Juveniles Adults
Lymbic system still developing: impacts memory, emotional regulation, primary sensory integration
Brain is fully developed
Cognitive Development (Piaget)
Take into consideration state youth is in: concrete operations or abstract thinking
In early stage of development youth is not capable of planning, may have difficulty understanding perspectives of others. This would make exhibiting or learning empathy difficult. Demonstrates limited coping strategies
Capable of planning (unless cognitive delay) limited coping strategies based on life experiences and AODA issues

12. Juveniles vs Adults Social Development Juveniles Adults
Attachments with primary caregiver (s) influence emotional regulation, self-esteem, self-efficacy, ability to form close relationships, empathy
Anxious Resistant Attachment- easily frustrated, difficulty coping with stress, social skill deficits
Negative attachment- aggression, conduct issues, other disorders
Use of sexual coping strategies to deal with loneliness and intimacy deficits (even if in an intimate relationship)
Use of power and control to compensate for social skills deficits. Frustration and lack of effective coping skills
(may include domestic violence)

13. Juveniles vs Adults Moral Development Kohlberg Juvenile Adult
Trauma history impacts development in this area
Cognitive development will also influence level or moral reasoning
Sexual Development
Puberty triggers an increase in sexual interest
Factors that impact the youth acting out include cultural, moral, religious, and parental attitudes/opportunities
(Behavior Chain)
Patterns of sexual behavior established

14. So what exactly are we working with?
14 minute ted talk

15. Advances in the Field of Trauma
This “new” focus also paralleled changes in the treatment of trauma
2001 Establishment of the National Childhood Traumatic Stress Network and subsequent research
Improved understanding of the impact of trauma
Development of treatments that were effective in promoting healing from trauma

16. JSO to ASBP
2006 renewed focus- not Juvenile Sex Offenders, Adolescents with Sexual Behavior Problems
Increased family involvement in the treatment process with the incorporation of family therapy whenever possible.
The incorporation of family groups as part of group treatment to facilitate family involvement in the treatment process
Focus on client and family strengths in the assessment and treatment planning processes
Increased focus on psychoeducation and skill building, particularly in group treatment, with less emphasis on clients needing to detail their inappropriate sexual behavior

17. ASBP outcomes
80% of clients will achieve at least 90% of their goals at discharge.
75% of clients discharged will have a reduction in their estimated level of risk as assessed with the ERASOR,
80% of clients discharged will demonstrate improvement on the Child and Adolescent Needs and Strengths Scale (CANS).
90% of clients who were living in their family homes will remain in the home at discharge.

18. Goals of the Program improve family functioning,
assess the whole child
provide a safe, supportive environment for the client to address his or her inappropriate behavior and develop skills for engaging in positive, healthy relationships
Focus on what we want to see, Not on what they “cannot do”
ability to develop positive relationships, healthy boundaries, pro social skills in communication and affect regulation, an integrated sense of self, and decision making skills.

19. Client Satisfaction
Red Striped-2014
Gold-2015
Purple Diagonal-2016

20. More than a sexual problem
Youth did not have history of delinquent behavior
Youth disclosed
trauma histories,
difficulty with peer relationships,
family conflicts
Porn
social media
Easy access to internet through many devices
Changes in the stress level of families also appeared to increase for many of the youth referred
Children adjudicated in Illinois frequently required to register
As we expanded our focus and asked more questions during the assessment, a more complex picture of the youth and families emerged.
Youth not learning what a healthy relationship is like as porn does not show real life.
Registry has a significant impact on youth on developmental opportunities as well as impact on adulthood.

21. Integrating Trauma Work in Treatment
2012, OHU developed a Category III NCTSN trauma treatment program utilizing an evidence-based framework called Attachment, Regulation, and Competency (Blaustein and Kinniburgh, 2010)
ARC integrated into ASBP treatment to address trauma experiences.

22. Current Program
Treatment with Adolescents With Sexual Behavior Problems

23. Program Philosophy
Adolescents with sexual behavior problems are first and foremost, adolescents
Developmental considerations are critical in case formulation
Adult models of sexual offending do not fit this population
Relationships matter, trauma histories impact relationships and needs to be assessed
Building resiliency is an important component to reduce risk
Treatment is driven by assessment

24. Program Philosophy Sexual behavior problems create harm
The origin of these behaviors is complex
Treatment needs to include the child’s family or caregivers
Treatment involves assisting the child to develop a plan for healthy living
Treatment for these youth is hopeful, with studies demonstrating that the recidivism rate is low for this population
Treatment is holistic with the goals of reducing risk for additional sexual acting out and improving function across life domains

25. Referrals Clients are referred primarily by the court and DCFS
Lake County, IL, McHenry County, IL, & Kenosha County, WI
Illinois Department of Children and Family Services
Clients are typically referred after they have been adjudicated delinquent
Adjudicated offense may not be a sex offense
Will accept clients pre-adjudication if they are admitting
Not all clients are court involved

26. First Step: Evaluation
Psychosexual evaluation
Is this client appropriate for community-based services to address the allegations of inappropriate sexual behavior?
What should treatment address?
Has this client developed a “pattern of deviant sexual interest”?
What is this client’s level of risk for sexual re-offense?
What strengths does this client and family present that can be used in the treatment process?
What is this client’s social emotional history that may impact this client’s success in treatment?

27. Adult Male Sex Offender ACES Study Levenson et al, 2016
Prevalence of early trauma is significantly higher for sex offenders than for males in the general population
Multiple maltreatments co occurred with other forms of family dysfunction
Almost half had an ACE score of 4 or more
38% reported history of child sexual abuse along with other family dysfunction
“A history of trauma can pave the way for problems with attachment, self regulation, and relational competence across the life span.” (p. 355)

28. Psychosexual Evaluation
Referral information, collateral sources, contacts for the evaluation
Mental Status and Behavioral Observations
Social History and Background, including trauma history
Data from Structured Tools and Psychological Testing
Sexual Arousal and Deviant Pattern of Sexual Behavior Assessment
Risk Assessment
Amenability to Treatment
Behavioral Impressions and Summary
Safety Plan
Preliminary Treatment Plan
Talk more specifically about these sections of the report

29. Safety Plans
Clients in the program are typically expected to follow a safety plan designed to provide external structure and guidance for supervision, particularly early in the treatment process
Based on the individual factors present in the case
Allegations, client’s age, family factors, etc.
Revised as clients make progress in the program and demonstrate an increase in ability to make positive decisions and engage in positive behaviors
These are “living documents”

30. Treatment

31. What is the impact of trauma?
Trauma can negatively impact physical, emotional and social development
Trauma impacts the way that individuals think, feel and behave
Trauma impacts individuals’ perception and sense of safety in the world

32. How do youth respond to trauma?
Re-experiencing or re-enacting the trauma
Maladaptive coping; possible delinquent behavior
Difficulty regulating emotions
Avoidance or numbing
Dissociation
Inability to trust others
Poor social skills
Regressive behaviors

33. Why address trauma when treating adolescent’s with sexual behavior problems?
Approximately 75% of the children involved in the juvenile justice system have experienced some form of trauma (Morrow 2012).
Many youth are unable to address their inappropriate sexual behavior without first resolving their own trauma
Treating trauma supports One Hope United’s holistic approach
Reducing trauma related symptoms decreases the likelihood that youth will continue to employ maladaptive coping strategies and engage in delinquent behavior

34. Individual Therapy All clients are seen individually
Recommendations for participation in family and/or group therapy are made on a case by case basis, depending on its appropriateness for each client
Recognition of the therapeutic relationship needing to promote a sense of safety
Therapeutic alliance/ Relational Engagement is important
Atmosphere of safety and acceptance
Non-shaming environment
Addresses the developmental concerns of adolescence as well as the problematic sexual behavior
Trauma work is done in individual therapy

35. Family Therapy Parental/caregiver involvement is key
Parental/caregiver education and skill development are targets in treatment
Family therapy is utilized in several ways:
Presentation of completed treatment work
Family relationship issues
Reunification
Attachment work
Skill sharing

36. Group Therapy Client are referred to group treatment when appropriate
14 – 16 week psychoeducational group
All clients in the group are adolescent males who have been identified as needing a skills group
Focus is on skill building and healthy living behaviors
Weekly topics identified including:
Healthy relationships, coping skills, boundaries, thinking errors, consent, communication, healthy sexuality…
Group process promotes support, acceptance, and empathy among members

37. Group Therapy
Family groups are provided at orientation and mid way through the group
This has allowed parents/caregivers to be more active participants in treatment
Parents are provided with updates regarding topics discussed
Provides parents/caregivers with opportunities to receive support from other parents/caregivers and group therapists

38. Parent Group
In Spring 2014, the program for the first time offered an eight week psychoeducational group for parents/caregivers of the adolescents in our program
Provided them with an opportunity to learn more about the treatment concepts that the adolescents learn in treatment
Presented them with information regarding attachment and self-care
It was our hope that by arming these parents/caregivers with this information, they would be better able to support their adolescent in treatment and gain a better understanding of sexual behavior problem treatment

39. Attachment, Self Regulation, and Competency in the Treatment Process
As we have discussed, the importance of treating trauma in this program has become clear to us at One Hope United. In that context we utilize an evidence informed model, ARC that was developed by Margaret Blaustein and Kristine Kinniburgh at the Justice Resource Institute in MA. I am going to take a bit of time to give you an overview of the model, and then discuss how this looks throughout the course of treatment. In particular, we use many of the concepts related to ARC within our groups.

40. What is ARC?
“The ARC framework is a components-based model that identifies three core domains of intervention for children and adolescents who have experienced trauma, and their caregiving systems (Blaustein and Kinniburgh 2010).”

41. ARC Framework Competency Regulation Attachment Trauma
Experience Integration
Executive Functions
Self-Development & Identity
Competency
Identification
Modulation
Relational Engagement
Regulation
Caregiver Affect Management
Attunement
Effective Response
Attachment
If you are familiar with the model, you may remember the triangle, this is a new graphic that is similar but includes the idea that all of these blocks are underneath TEI, whether the child has addressed them or not. Our task is to assess and help the child deal with each of them in a healthy way. This is a hot off the presses graphic, not in your slides, happy to send it out to Bethany tho.
Engagement
Psycho -education
Routines & Rituals
Graphic by Jeremy Karpen; Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

42. Consistent Behavioral Response
8 Primary Skills: Building Blocks
Expression
Executive Functions
Self Dev’t & Identity
Routines
Competency
Identificat.
Modulation
Regulation
Consistent Behavioral Response
Psychoed
Caregiver Affect Mgmt.
Attunement
These eight blocks are the components of each domain. Attachment includes caregiver affect mgmt, attunement, and consistent behavioral response; Regulation includes affect identification and modulation, and competency includes executive functioning, affect express, and the development of self and identity. We will talk about expression with regulation as it really a block that can go in both domains.
Attachment
Engagement
Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005 42

43. Domain 1: Attachment

44. Primary Goal of Attachment Domain
Work with identified caregivers to help them manage their own emotional responses and create a safe environment that is able to support youth in meeting developmental, emotional, and relational needs.
This is important with this particular population in that these families are often reacting to the events of disclosure and court in such a way that the youth may shut down, avoid or disengage from treatment. This is not the family’s intention, however they are reacting, in a sense they are having their own trauma responses.
Kinniburgh & Blaustein 2010

45. Caregiver Management of Affect
Caregivers must be able to regulate their own emotional responses before they are able to assist youth with managing their affect.
Goal of this domain is to assist caregivers with understanding, managing and coping with their own emotional responses.
Kinniburgh & Blaustein 2010

46. Caregiver Management of Affect: Interventions
Psychoeducation
Normalize caregiver emotional response
Help caregivers identify challenging situations and teach them to attune to their reactions in these difficult situations
Model affect regulation techniques
- deep breathing
- progressive muscle relaxation
- time out’s
Assist caregivers with building a support system
We discuss these interventions with parents, and when we are able to implement the parent group, we found that this supports parents as they try to sort out their own reactions to what has occurred
Kinniburgh & Blaustein 2010

47. Attunement
Youth often have difficulty effectively communicating their emotions and needs. As such, they often utilize negative behaviors to express these emotions and unmet needs.
Goal of this domain is increase caregiver’s ability to accurately interpret behaviors and respond to underlying emotions and unmet needs.
Kinniburgh & Blaustein 2010

48. Attunement: Interventions
Provide caregiver with psychoeducation on trauma, trauma responses and trauma reminders
Teach caregivers to be “feelings detectives”
- i.e., help them learn to read their child’s cues
Teach/model reflective listening skills as a means of helping caregivers to communicate support to youth
Utilize activities such as feelings charades or mirroring as means of practicing attunement
Our program serves a wide age range of kids, these strategies can be adapted within family sessions for the developmental stage that the child is at. We also practice attuning to others in group settings where we encourage youth to provide feedback to each other based on what they notice about their peer.
Kinniburgh & Blaustein 2010

49. Consistent Caregiver Response
Consistent, predictable responses increase a sense of safety and security in youth.
Goal of this block is to help caregivers learn to respond behaviors in a safe, consistent and predictable manner.
Kinniburgh & Blaustein 2010

50. Consistent Caregiver Response: Interventions
Emphasize the use of praise and positive reinforcement and assist caregivers with incorporating this into their daily routine
Provide caregivers with information on natural consequences and teach them about the use of ignoring, limit setting and time-out as a means of managing behavior
Educate caregivers on the trauma response that may be encountered when utilizing praise or limit setting
Kinniburgh & Blaustein 2010

51. Routines and Rituals
Often, traumatized youth have experienced chaotic and unpredictable environments. The establishment of routines and rituals helps to increase youth’s feelings of safety. Additionally, routines and rituals help to build trust and reliability in the attachment relationship.
Goal of this integrating strategy is to help caregivers and youth develop rituals and build routine into their daily life
We talk about routines and rituals throughout. This strategy is important as it promotes predictability and clarity with expectations, which is often a challenge for families. We talk about it in the context of attachment particularly because of how it also promotes a sense of safety ad the importance of that sense of safety. Why would you think safety for kids in this type of program might be useful?
Kinniburgh & Blaustein 2010

52. Routines and Rituals: Interventions
Create structure and consistency in the therapeutic environment
Work with caregivers to establish appropriate daily routines. Target the following areas:
-Bed time
- Meal time
- Homework time
- Transitions
These are some examples of where the family can build in routines, we also build this in our sessions, they have a beginning, middle, and end and that is clear.
Kinniburgh & Blaustein 2010

53. Domain 2: Self-Regulation
Questions, comments?

54. Primary goal of self-regulation domain
Help youth to successfully identify, regulate and share their emotional experiences
Kinniburgh & Blaustein 2010

55. Affect identification
As trauma overwhelms a youth’s ability to cope, they often disconnect from their feelings or engage in maladaptive coping skills. As a result, they struggle to identify and differentiate between emotional states.
Goal of this block is help youth learn to accurately identify and differentiate their emotional states. Additionally, goal is to help youth understand what prompts these emotional states.
Affect identification is frequently a skill that the youth we serve do not have. The majority of our cases are boys, and some of this may be related to how our society socializes boys, some of it may be due to development, but this is an area that we find we have to spend some time in. If kids are not able to accurately identify their internal emotional experience, they will respond to events based on their inaccurate perceptions, which may well include hurt, fear, sadness etc…Under those conditions, the likelihood of a negative behavior increases.
Kinniburgh & Blaustein 2010

56. Interventions Provide youth with psychoeducation on feelings
- Feelings charades, feelings charts, bibliotherapy
Assist youth with identifying and understanding triggers
Normalize emotional experiences
Help youth understand the way their body responds to different emotions
In group we spend two to three sessions on regulation. One group is specific to identification. In order to help kids tune into this, we use some of these ideas and also in your packets I have given you a homework assignment we use. Kids almost always like to listen to music. When we use homework, we try to tie this to something that we know that they are likely to do during the week, (take a quick look at the hw page)
Kinniburgh & Blaustein 2010

57. Modulation
The traumatic stress response that occurs in the brain contributes to youth’s difficulty with modulating their emotions.
Goal of this block is to help youth develop safe and effective coping strategies as a means of regulating their emotions and states of arousal.
Modulation is another area that we end up spending at least two groups on. We talk about the importance of learning to identify the degree of energy that they are feeling (more energy increases the likelihood of impulsivity) and then using coping skills to modulate that energy. We can then build on these concepts to develop a coping skills menu or toolbox for the youth to use at home.
Kinniburgh & Blaustein 2010

58. Modulation: Interventions
Teach youth to decrease their level of arousal by engaging in activities such as deep breathing, progressive muscle relaxation, visualization, etc…
Teach youth to increase their level of arousal by engaging in activities such as jumping jacks, dancing, etc…
Increase youth’s ability to shift between levels of arousal by engaging them in activities such as ball rolling at various speeds or movement at varying speeds
Create a “coping skills toolbox”
Kinniburgh & Blaustein 2010

59. Integrating Strategy: Psychoeducation
Used throughout treatment
Provided to youth and family
Provides a context
Normalizes and validates when appropriate
Again the idea of psycho education is very important, we as clinicians may have a good understanding of how/why certain behaviors evolve, why we are asking youth to do certain things, and the skills needed to support change, but the people we are trying to help may not have a such a good idea of these issues. Being mindful of the need for this helps us to be proactive with providing this throughout the treatment process.

60. Domain 3: Competency
Questions?

61. Primary Goal of Competency Domain
As trauma derails development, goal of this domain is to assist youth with achieving key developmental tasks as a means of supporting ongoing healthy development and resilience
Its very important to recognize that as we help youth and families have a context, such as ARC and the literature related to adolescent development and sbp for understanding what has happened, and the responses, this in no way minimizes the importance an impact of the offensive behavior. Accountability is discussed throughout treatment, and discussed from the perspective of the self control that this gives.
Kinniburgh & Blaustein 2010

62. Affect Expression
Youth’s attempts at sharing their emotional experiences may have been met with anger, rejection or indifference in the past. As such, they are unaware of how to effectively communicate their emotions.
Primary goal of this block is provide youth with support as they learn to effectively share their emotional experiences.
Expression, or communication is also very important for these kids. In ARC, this is considered a competency. It is a skill that requires the foundation of feeling safe enough (attachment), clear enough about what you are thinking and feeling (regulation) to let someone know what is really going on, not an easy task for many of us.
Kinniburgh & Blaustein 2010

63. Affect Expression: Interventions
Assist youth with identifying safe people with whom they can share their emotional experiences
Model appropriate social skills, verbal and non-verbal communication as a means of helping youth identify the right moment to share their emotions and communicate them in an effective manner
Kinniburgh & Blaustein 2010

64. Executive Functions
The pre-frontal cortex is responsible for executive functioning which includes problem solving, impulsivity and decision making skills. The pre- frontal cortex of youth who have experiences trauma is often underdeveloped.
Primary goal of this domain is to assist youth in the area of executive functioning and to improve their ability to make decisions and delay gratification.
Kinniburgh & Blaustein 2010

65. Marshmallow Test
So the internet is a mixed blessing right? We use videos to illustrate points both in training and in treatment. Executive functions really has to do with the idea that as our brain develops, our capacity to take in a variety of pieces of information, process it by evaluating it, considering our values, thinking of consequences and making a choice also develops. For adolescents, we know that this capacity is not completely developed, this is a very short video that illustrates how challenging decision making can be and how not all kids have the same capacity.

66. Executive Functions: Interventions
Teach problem solving skills which include the following steps:
Recognize that there is a problem
Establish safety and override the fight, flight, freeze
response
Identify and understand the problem
Brainstorm possible solutions
Evaluate possible consequences of each solution
Implement and evaluate the best solution
Kinniburgh & Blaustein 2010

67. Self Development and Identity
Trauma impacts youth’s ability to establish a positive, coherent sense of self.
Support youth as they explore and develop their personal identity and sense of self across four domains.
Sense of self is very important. If I see myself I a positive light, and see a future, it becomes less likely that I will fall into hopelessness, helplessness. Again, this is hard to do without feeling worthwhile and feeling that those around you care for you.
Kinniburgh & Blaustein 2010

68. Self Development and Identity: Interventions
The Unique Self (Individuality): Help youth identify their own personal attributes including likes, dislikes, spiritual beliefs, talents, values, etc…
-Personal collage, “All About Me” book
The Positive Self (Self-esteem/Self-efficacy): Assist youth with identifying positive aspects of self.
-Pride Wall
Cohesive Self (Integration): Help youth establish a sense of self that incorporates a variety of life experiences, both past and present.
-Life books
Future Self (Future orientation and possibility): Build child’s ability to establish future goals and imagine their future self.
-Future self drawing, consider goals 5, 10, 15, 20 years in future
Kinniburgh & Blaustein 2010

69. Trauma Experience Integration
Youth who experience complex developmental trauma develop increasingly efficient patterns of behavioral, affective, cognitive, physiological, and/or relational patterns of response to help them cope and manage with stressors.
Goal of this domain is to enhance the client’s ability to engage in present life
In trauma treatment, this is the goal. For this program, we also would like the youth and families we work with to have a coherent narrative and to feel that they can make sense of what has happened to them, knowing that we may not achieve this in its entirety and that the youth may need to revisit this.

70. Trauma Experience Integration: Interventions
Explore youth’s attachment patterns, and meaning making about self and relationships
Process specific traumatic experiences
Narrative – writing, storytelling, drawing, play
Parent/caregiver bears witness
For youth that trauma treatment specifically is part of their treatment plan, these are some of the activities we are thinking about in this area.

71. Integrating Strategy: Relational Engagement
So the final strategy I want to talk a bit about may well be the most important. As clinicians we know that the youth and families we work with who are engaged, who trust us, and who believe that we are working with them, do the best and have the best outcomes. This strategy is about engagement. ARC has a process that is taught during the model’s training that really sets this in motion. In some CBT practices however there is not so much attention paid to this aspect. My recommendation, pay attention to it. The literature from the Good Lives Model as well as some of the recent articles related to sbp recidivism and outcomes all suggest that this is a complent to maintain awareness of. (Bibliography)

72. Treatment Process
The program at One Hope United has a structure that utilizes a “phase of treatment” system.
At the onset of treatment, clients and their caregivers are provided with a program overview which contains descriptions and examples of related assignments for each phase of the program.
We emphasize to the client and family that treatment is a process, and that movement through the program is not necessarily linear
We have just provided you with an overview of ARC and some thoughts about how we might implement this in treatment. Our sbp program is typically 12 to 18 months in length, it is important to let youth and families know that treatment does indeed have a beginning, middle, and end. We use the concept of treatment phases to communicate this,

73. Phase One: Entry
This phase of treatment acknowledges that the client who has just begun the treatment process may require more external controls than those who have been actively engaged
Safety plan is implemented and your treatment goals are established.
Some examples of external controls that may be used in this phase include:
Detention or residential placement
Home detention
Probation/supervision rules
Safety Plan implementation
Parental controls
Treatment tasks in this phase may include:
Attendance to treatment, compliance with all treatment expectations, assignments, fees etc.
Compliance with court, treatment, and parental expectations
These may look familiar to many of you, the idea of steps, phases, or a process is certainly not new. What we try to stress is that treatment is a process. Youth can always have a sense of where they are in the process, however it is also important to note that the process may not be linear. The first “phase” is really around the beginning of treatment and establishing goals, expectations, working relationships. This is where we would talk about the program, talk about our philosophical approach, explain the process, and provide support as the youth and family begin the process. I frequently talk to youth about how one purpose of this first phase is to reinforce their ability to follow rules.

74. Phase Two: Engagement
This phase of treatment involves the client assuming full responsibility for their problematic behavior, not only sexual behavior problems but also behaviors in other areas of their life
Indications of this high level of responsibility include:
Client’s descriptions of behaviors do not include minimization, justifications, or attempts to blame others
Consistent compliance with court orders, parental, and treatment expectations
Able to identify thinking errors in self and others
 Treatment tasks in this phase may include:
Completed homework assignments
Active participation in individual therapy
Developing an understanding of “Four Pre Conditions” concept
Identifying skills that need to be improved upon
We call the second phase engagement, we mean not only engagement with treatment providers, but with the program itself. This is a time where shared language is developed, where we model attunement, where we begin to introduce concepts that we find helpful for youth and families to begin to understand where this behavior may have come from. The issue of responsibility is important. This does not mean necessarily that youth “fully disclose” all of their inappropriate behavior. Our program has not required polygraphs for over 8 years. We believe that these can create more issues than solve. That being said, we have recommended these at times, for youth that are older and for specific clinical reasons. The recent ATSA statement regarding polygraphs and youth is consistent with our practice.

75. Phase Three: Understanding Patterns of Behavior
Identification of the various components of patterns of behavior that the client may engage in, both sexual behavior problem patterns and other behavior problem patterns.
Clients begin to be able to recognize points at which they could interrupt these patterns and make more positive choices
Treatment tasks in the phase may include:
Interrupting distorted thinking in yourself and others in group and individual sessions
Active participation in individual and/or group therapy
Active participation in family therapy, when appropriate
Completion of “pattern” packet
During this phase of treatment, clients increase their ability to use skills that have been learned in treatment
Anger management, stress management, communication skills, resolving conflicts, boundaries , healthy relationship skills, etc.
We have talked about how early in the field the idea of “cycle” was used with youth, as it is with adults, again, given the research and consistent with both the GLM and the SAFE T program, we talk about patterns of behavior. In terms of ARC, this is the phase where skill building and regulation tasks come in. As youth are better able to use these skills, they gain confidence, and gain in their ability to engage in pro social activities, thus building resiliency.

76. Phase Four: Using What I Have Learned
Practicing the use of healthy living skills during and outside of sessions. This phase also involves demonstrating the ability to actively interrupt negative patterns as they occur.
Indications that you are working in this phase include:
Verbalizing and using ways to interrupt negative behaviors as they occur
Being able to understand the impact of trauma and demonstrate empathy for others
Being able to have positive and healthy peer relationships
Treatment tasks in the phase may include:
Active involvement with family sessions, if appropriate
Clarification/apology sessions when appropriate
Beginning to develop a plan for healthy living
Continued involvement in individual and/or group therapy
Working on resiliency and positive relationships with peers, family members, and community members
Implementation and what this means in context of the youth and their sense of identity is the focus of this phase. Competency activities are focused on here

77. Phase Five: Committing to a Healthy Living Plan and Graduation
This phase of treatment focuses on developing a plan for engaging in a healthy lifestyle
Interpersonal and family relationships, positive activities, coping skills, goals
Tasks in this phase may include:
Completing a written plan for a healthy lifestyle and reviewing this with family members
Completion of clarification/apology work
Being able to take a leadership role in group, if attending
Being able to utilize specific strategies in the healthy living plan
And as the youth demonstrates their ability to utilize skills and develop a healthy living plan, increasing conversations about graduation occur. In this program we do a considerable amount of reunification work. Due to time, we can’t go into this piece too much, suffice it to say that we think this is very important, that a central goal is to assist this youth and family with healing relationships, whenever possible.

78. Collaboration
Therapists maintain regular contact with the referral source via phone contact when needed and written monthly progress reports
Monthly case staffings with probation/court services
Address client’s progress and any barriers to progress
Just as a final note, we believe in collaboration with court services, other providers, schools, and we will see kids in community settings if necessary. As with ARC, we want to remove barriers for treatment and actively engage youth and famiies in the healing process.

79. ASBP-Youth
So, does this all work? We gather pre and post data from the youth and families that we work with, these final few slides summarize this data that has bee collected over the past two years. The “N” for this is____________ This is what youth say at the end of tx in terms of knowledge.

80. ASBP Group
This is a summary of youth opinion related to group

81. Comments- Best And these are statements that the youth shared with us
Learning about thinking errors, boundaries, and how to change negative thoughts
Apology letters
Closure letter
Having a therapist that challenged me on my thoughts almost always motivated me to do better.
Group because it helped me interact with other guys
Talking about my sexual thoughts
Apology letter
Individual counseling (4)
Learning about healthy relationships and how to use them in my personal life
Telling my story in group
Thinking errors
Cycle packet
Comments/Hardest:
Learning about thinking errors and my view of women
How long it took me to finish
Talking about my life
Group therapy and changing therapists
Group helped me through alot
Chapter 12 packet because it was so lengthy
How we went over the body changes
Coming
Treatment book
Helping me figure why I did it and finding ways to not do it again
Speaking out about my situation and the things I have done
Coming to group in the beginning (2)
Getting to learn new things
Group because I didn’t trust anyone and I wasn’t comfortable talking about my behavior to others.
Boundaries and empathy
The learning
Nothing was hard to me
The bridge of consent
Doing the packets and getting them done
To learn coping strategies (2)
Just attending group (2)
Increased kindness
And these are statements that the youth shared with us

82. Comments- Improve
If I could go back and fix things and fix what I have done
Less homework
Try to have a male therapist with a different mindset and experiences
I would change the group times
More food groups
I actually don’t know because if I didn’t grow through what I went through then I don’t think I would’ve learned everything I’ve learned before it was too late
I wouldn’t change anything
Nothing (10)
I wouldn’t change anything about therapy at One Hope
And the not so good

83. Thank You! Questions? Please complete your evaluations!