Jan Looman, Ph.D., C.Psych. Kingston, Ontario

Jan Looman, Ph.D., C.Psych. Kingston, Ontario Jan1looman2@yahoo.ca
Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for Clinicians Jan Looman, Ph.D., C.Psych. Kingston, Ontario

Assessment and Treatment of High Risk Sexual Offenders: Practical Guidelines for Clinicians
Note: The views expressed here are the views of the author and do not reflect the views of the Correctional Service of Canada

Outline Models of Treatment - RNR vs. GLM Describe triage process for sex offenders in Ontario/Canada What do I mean by “high risk/needs”? Describe treatment process for High Risk/Needs Sex Offenders Link to community treatment – continuity of care

Models of Treatment What really is RNR? RNR vs. GLM
Is the Good Lives model different? Before we go on to discuss treatment itself I think an explication of our treatment model is required. Lately there has been a lot of fuss in the literature and at conferences regarding the GLM with claims being made that it is a vast improvement on existing treatment models. But is it?

Models of Treatment RNR model is not a theory of intervention in itself – it represents principles of effective correctional intervention (Andrews & Bonta, 2010) derived from Andrews and Bonta’s general personality and cognitive social learning (GPCSL; Andrews & Bonta, 2010) theory of criminal behavior.

Models of Treatment GPCSL posits that crime results when the personal, interpersonal, and community supports for behavior are favorable to crime Strong influences - antisocial attitudes, antisocial associates, a history of offending, antisocial personality traits. Weaker influences - familial difficulties, poor adjustment to work and school. Possessing antisocial attitudes and having antisocial associates are considered particularly strong influences, as is a history of offending and antisocial personality traits. Weaker influences include familial difficulties and indicators of social achievement, such as work and school. Therefore, the GPCSL takes a broad perspective, recognising that personal, interpersonal, and social factors are involved in the acquisition and maintenance of criminal behavior

Models of Treatment RNR Principles – guide us in designing intervention within the GPCSL theory The Risk Principle - that higher levels of intervention should be reserved for higher risk cases - low risk offenders should receive no, or very little intervention. Risk is to be determined through validated actuarial assessment of static and dynamic risk So in keeping with this principle we use structured risk assessment tools such as the Static-99R or the SORAG to determine who we provide treatment

Models of Treatment The Need Principle - interventions should target criminogenic needs (dynamic risk factors). Central Eight risk/need factors (Andrews & Bonta, 2010): antisocial associates, antisocial cognitions, antisocial personality pattern, history of antisocial behavior, substance abuse, family–marital, school–work, leisure–recreation. Important to note that Hanson’s meta analyses have linked these to all types of recidivism, so they are valid targets for SO treatment

Models of Treatment Sex offender specific criminogenic needs identified by Mann, Hanson & Thornton (2010) Sexual preoccupation Sexual deviance – esp. deviant arousal to children; multiple paraphilias Offense-supportive attitudes Emotional congruence with children

Models of Treatment Sex offender specific criminogenic needs (con’t)
Lack of emotionally intimate relationships with adults Lifestyle impulsiveness Poor problem solving Resistance to rules/supervision Hostility Negative social influences

Models of Treatment Other factors identified as “Promising” criminogenic needs: Hostility toward women Machiavellianism Lack of concern for others Dysfunctional coping Sexualized coping Externalized coping Mach. - personality is characterized by manipulation and exploitation of others, with a cynical disregard for morality and a focus on self-interest and deception Lack of concern for others = PCL-R facet 2 - described as selfish, cynical, and willing to be cruel to meet their own needs. They appear indifferent to other people’s rights or welfare, except as it influences their own interests.

Models of Treatment Non –Criminogenic Needs Hanson & Morton-Bourgon (2005) Force/violence in sex offending Neglect or abuse during childhood Sexual abuse during childhood Loneliness* Low self-esteem Lack of victim empathy Denial of sexual crime * Low motivation for treatment at intake Poor progress in treatment (post) Loneliness has been found in the DSP to be related to recidivism but other studies not Recent research has found that denial is related to recidivism for some offenders – I’ll go in to that more later It is possible that much of what passes as poor victim empathy could be better construed as justifications that offenders used to distance themselves from a deviant identity. It is also plausible that for some individuals poor victim empathy may be a symptom of the more general problem of lack of concern for others (see above). Re: neglect/abuse/sexual abuse in childhoood – recent research (Jesperson, Lalumiere & Seto, 2009) shows higher rates of sexual abuse in sex offenders and other research (complex PTSD, Courtois, Ford & Herman, 2009) shows that childhood trauma is associated with a variety of negative outcomes. However, the research suggests that these may lead to the development of problematic behaviour but they are not related to the maintenance of it.

Models of Treatment Within the Need Principle non-criminogenic needs not relevant targets for intervention A caveat to this: dealing with a noncriminogenic need may be an important strategy in the context of addressing a specific responsivity factor. Treatment providers must build on strengths and remove barriers to effective participation enhancing responsivity (Andrews, Bonta & Wormith (2011)

Models of Treatment The Responsivity Principle
general - the most effective interventions tend to be those based on cognitive, behavioral, and social learning theories the relationship principle (Andrews, 1980) (establishing a warm, respectful and collaborative working alliance with the client) and, the structuring principle (influence the direction of change towards the prosocial through appropriate modeling, reinforcement, problem-solving, etc.) Note – in 1980 Andrews identified the importance of the therapeutic relationship in affecting change in antisocial attitudes among inmates – randomly assigned probationers to officers who were rated on their warmth, empathy, and interpersonal skills – lower recidivism rate and greater attitude change associated with the more skilled officers

Models of Treatment The Responsivity Principle
specific responsivity - the treatment offered is matched not only to criminogenic need but to those attributes and circumstances of cases that render them likely to profit from that treatment Here you may have to address mental disorders, anxiety, introduce interventions to accommodate a learning disability etc. Present material appropriate for the audience – reading level, visual vs. language based

Models of Treatment Responsivity Factors (Looman, Dickie & Abracen, 2005; Olver, Stockdale & Wormith, 2011) psychopathy Low motivation/ denial/minimization low intellectual functioning/lack of education hostile interpersonal style/disruptive Mental health difficulties personality profile Here you may have to address mental disorders, anxiety, introduce interventions to accommodate a learning disability etc. Present material appropriate for the audience – reading level, visual vs. language based

Models of Treatment Summary RNR
Treatment directed toward higher risk clients Addresses known criminogenic needs Cognitive behavioural/social learning approaches Emphasis on effective therapist characteristics and role modeling delivered in a manner appropriate for the client group

Evidence for RNR Dowden and Andrews (1999) - meta-analysis of 25 studies of treatment for female offenders effect sizes larger when criminogenic needs were targeted. treatment services which adhered to all of the RNR principles found to be related to the greatest reductions in recidivism, while treatment rated as inappropriate had the weakest effects. targeting vague personal/emotional targets, family interventions not addressing criminogenic needs, and other non-criminogenic personal treatment targets were associated with no reduction in recidivism. any treatment programming significantly stronger effect than criminal sanctions alone

Evidence for RNR Dowden and Andrews (2000) - meta-analysis 35 studies of treatments for violent offenders criminal sanctions alone no effect on recidivism any human service delivery  significant positive effect. programs which adhered to RNR principles were more effective than those which did not Programs targeting criminogenic needs associated with a moderate effect size - those which did not produced no significant reduction in recidivism.

Evidence for RNR Dowden and Andrews (2000) (con’t)
Programs that adhered to all three RNR principles produced the largest effect sizes. correlation between effect size and number of criminogenic needs targeted was .69 (p <.001) correlation between effect size and number of non-criminogenic needs was -.30 (p <.05). So as the number of noncriminogenic needs targeted increases, the effect sizes decreases

Evidence for RNR Hanson, et al. (2009) studies of sexual offender treatment adherence to the RNR principles  greater reductions in recidivism effect was linearly related to the number of RNR principles adhered to. programs which adhered to none of the principles  a negative treatment effect.

Evidence for RNR Dowden, Antonowitz and Andrews (2003) - meta-analysis of 24 studies of treatment programs which employed an RP approach in the delivery of treatment.- (7 addressed sex off). moderate overall effect size for RP programs Coded presence of various aspects of the RP approach (i.e., offence chain, relapse rehearsal, advanced relapse rehearsal, identification of high risk situations, training significant others, Booster sessions, coping with failure situations)

Evidence for RNR Dowden et al (2003)
Overall, the greater the number of RP components employed in treatment, the stronger the treatment effect (r = .38, p < .01). found that RP programs which adhered to all three RNR principles had the greatest impact, while those that adhered to none of the principles had no impact on recidivism.

Evidence for RNR Summary
Treatment approaches which adhere to RNR principles effective in reducing recidivism for violent offending, female offenders, sexual offenders RP approaches which adhere to RNR principles also effective Approaches which focus on noncriminogenic needs (for SOs internalizing psychological problems denial, low victim empathy, and social skills deficits) non-effective or even harmful Note – didn’t review research related to general (any) recidivism but the results are the same Internalizing – depression, anxiety

Models of Treatment Good Lives Model

Good Lives Model Assumptions about Human Nature
Assumes all human being are practical decision-makers and have similar aspirations and needs one of the primary responsibilities of parents/teachers to equip people with the skills/tools to make their own way in the world

Good Lives Model Assumptions about Human Nature (con’t)
People formulate plans and intentionally modify themselves and their environment in order to achieve goals In order for people to function effectively their basic needs must be met

Good Lives Model Assumptions about Human Nature (con’t)
Primary human goods – have their origins in human nature and have evolved in order to help people establish strong social networks, survive and reproduce People derive a sense of who they are and what matters from what they do (Practical identity) Therefore in rehab need to provide offenders with an opportunity to acquire a more adaptive practical identity PHG =basic human needs Secondary good – the means of achieving the primary good – e.g. good of relatedness= desire to form warm affectionate bond with someone else – secondary good = friendships

GLM on RNR Criticize RNR approaches
focus on risk reduction/management unlikely to motivate offenders – need to have approach goals pay attention to offender as a whole - RNR sees offender as “disembodied bearer of risk” Lack of focus on non-criminogenic needs – therapeutic relationship RNR approaches “one-size fits-all” Point # 2 Related to this is a lack of appreciation for personal choice in setting treatment goals and the importance of gearing treatment to the needs and interests of offenders while still modifying their level of risk. Thus, the claim is that the RNR model does not pay enough attention to the role of personal or narrative identity and agency (i.e., self‐directed, intentional actions designed to achieve valued goals) in the change process. This problem suggests that the RNR model lacks external consistency, unifying power, and practical utility (fertility). Point 3 Claim that the RNR model suffers from a lack of explanatory depth and external consistency. This criticism refers to RNR model's narrow view of treatment and a tendency to focus on a narrow set of goals relating to risk reduction. Does not acknowledge that rewards sought by individuals are at least partially determined by the basic human needs and the goods (activities, experiences, objects) that satisfy them. If human beings do have a natural inclination to seek certain types of goods, then rehabilitation efforts should ensure that there is some recognition of this fact and that attempts are made to facilitate (or at least not frustrate) their achievement.

What Does the GLM Say Nine* Primary Human Goods (Ward & Marshall (2004): 1. life (including healthy living and optimal physical functioning, sexual satisfaction); 2. knowledge; 3. excellence in play and work (including mastery experiences); 4. excellence in agency (i.e., autonomy and self-directedness); Laws & Ward (2011) say 10 – add community – sense of belonging Interesting – Laws & Ward say the list is extensive but not exhaustive while Ward & Marshall (2004) say the list of nine is comprehensive (i.e., complete) 1. life (including healthy living and optimal physical functioning, sexual satisfaction); - physical needs and factors that are important for healthy living/functioning – food, water etc. – secondary good – exercise, diet-conscious, managing health problem 2. knowledge; - people inherently curious and desire to understand themselves and their environment – secondary good = education, attending school, vocational training etc. 3. excellence in play and work (including mastery experiences); - engage in leisure activity for it’s own sake – mastery in work-related or recreational activities – secondary – participating in sports, undergoing apprenticeship, hobbies, mentoring 4. excellence in agency (i.e., autonomy and self-directedness); - the desire to be able to formulate ones own goal and act on those goal (master of one’s own domain) – secondary employment that allows autonomy, financial independence, asserting oneself, attempting to dominate others

GLM Nine Primary Human Goods (con’t)
5. inner peace (i.e., freedom from emotional turmoil and stress); 6. relatedness (including intimate, romantic and family relationships) and community; 7. spirituality (in the broad sense of finding meaning and purpose in life); 8. happiness; and 9. creativity. 5. inner peace (i.e., freedom from emotional turmoil and stress); - emotional self-regulation ability to achieve emotional equilibrium secondary – engaging in balanced lifestyle, building positive relationships, learning emotional control, physical exercise, sexual activity 6. relatedness (including intimate, romantic and family relationships) and community; - desire to establish warm affectionate bonds with others secondary – romantic relationships, friendships, spending time with friends, family 7. spirituality (in the broad sense of finding meaning and purpose in life); - desire to discover and attain a sense of meaning and purpose in life – seeking religious truth/involvement, spiritual connect to transcendent being, or simply the sense of being a part of a larger whole – secondary – belonging to a church, practising religion 8. happiness; - overall experience of being content and satisfied with one’s life – secondary – establishing relationships which lead to please, sexual partners, eating, playing sports fir pleasure 9. Creativity – desire for novlety and innovation - work parenting, gardening, painting, playing an instrument

GLM & Offending Criminogenic needs = internal or external obstacles that frustrate and block the acquisition of primary human goods Individual lacks the ability to obtain the good in a prosocial manner and is unable to think about his life in a reflective manner i.e. criminogenic needs =deficiency in agency and conditions that that support agency

GLM & Offending 4 major difficulties with offender’s life plans that lead to offending Means he uses to secure goods Inappropriate strategies  Violation of norms Lack of scope – important good missing e.g., lack if connectedness  feelings of loneliness/inadequacy

GLM & Offending 4 major difficulties with offender’s life plans that lead to offending (con’t) Conflict among goods sought – e.g. attempt to pursue good of autonomy leads to relationship issues Lack of capability – knowledge/skills deficits

GLM & Offending Two routes to the onset of offending
Direct – offending is the primary focus – e.g., offender may lack the relevant competencies and understanding to obtain the good of intimacy with an adult – offending = striving for fundamental goods – intentionally seeks goods through criminal activity. Indirect – pursuit of a good increases the pressure to re-offend – e.g. conflict between good of relatedness and autonomy leads to break-up of relationship  loneliness/distress alcohol use  offending

GLM & Offending Offenders search for primary goods in their environments under the guidance and constraint of their practical identity Act in ways that they think will satisfy them Sex offending arises because people make faulty judgements Lack of forethought or knowledge concerning relevant facts Practical identity – who they see themselves as – psychologist, father, scientiest

GLM & Intervention Should be a direct relationship between goods promotion and risk management Rehabilitation = holistic reconstruction of the self  new practical identity Focus on promotion of goods is likely to automatically eliminate or modify risk factors Attitude of therapist – offender viewed as someone attempting to live a meaningful, worthwhile life in the best way he can in the specific circumstances confronting him Attitude – accepting, nonjudgemental

GLM & Intervention Tailoring of therapy to match the individual client’s life plan and their risk factors Therapeutic task shaped to suit the person in question Focus on approach goals rather than avoidance of risk factors

GLM & Intervention Assumptions/Considerations (Laws & Ward, 2011)
Offenders lack many of the essential skill/capabilities to achieve a fulfilling life Criminal behaviour = attempt to achieve desired goods but the skills/abilities absent – alternatively: Criminal behaviour arises from an attempt to relieve a sense of incompetence, conflict, or dissatisfaction that arises from not achieving valued human goods.

GLM & Intervention Assumptions/Considerations (con’t)
Laws & Ward (2011) The absence of certain goods more strongly related to offending**: Self-efficacy/sense of agency Inner peace Personal dignity/social esteem Generative roles and relationships (work, leisure) Social relatedness (associates). Note: Laws and Ward (2011) make this claim but offer no research to support it – the first three are directly contradictory to meta-analytic research which I summarized earlier that demonstrates that these are not risk factors and that targeting them is inappropriate

GLM & Intervention Assumptions/Considerations (con’t)
Risk of offending reduced by assisting individuals to develop the skills/abilities to achieve the full range of human goods Intervention = activity that adds to an individual’s repertoire of personal functioning rather than simply removing a problem or managing a problem Note: Laws and Ward (2011) make this claim but offer no research to support it – the first three are directly contradictory to meta-analytic research which demonstrates that these are not risk factors

Evidence for the GLM Laws & Ward (2011) indicate (p. 202) that the GLM has empirical support – however they fail to offer any citations The area of positive psychology generally is empirically based however this cannot be taken as evidence that such approaches are effective with offenders E.g. Deci & Ryan (2000) - self-determination is positively correlated with personal well-being

Evidence for the GLM Specific to Offenders?
Case studies – which do not tell us whether or not effective in reducing recidivism or more effective in addressing criminogenic needs E.g. White, Ward & Collie, 2007 – Mr. C. gang member with long criminal history of violence including sexual violence Noted that he had engaged in RNR based interventions on previous sentences Remained in pre-contemplation and rigid antisocial attitudes, continued drug use Did not see how the material from the programs applied to him – gang identified

Evidence for GLM Mr. C. (con’t) Treatment according to GLM
Outcome – 14 months following release Disclosed two violent incidents “The first involved a retaliatory action after being pushed to the ground at a party. … The second relapse occurred in response to his partner being insulted and offended. Mr. C’s reaction included “smashing” the victim and entering an emotional state synonymous with the abstinence violation effect Phase 1 – personal visualization of a new me – future focus - university, obtain a drivers license, improved intimate relationships, make family proud Phase 2 - in order to accomplish  reduction in drug use, prosocial peers, prosocial attitudes, detachment from gang Phase 3 e.g. Mr. C pursuit of the primary human goods of happiness, friendship, and intimacy through the secondary goods of his gang membership, associated violence, substance abuse, and predatory sexual behaviour. - access to his primary human goods of happiness, friendship, and intimacy were blocked (i.e., prevented) by his criminogenic needs (i.e., violence propensity, offence-related sexual arousal, relationship difficulties, substance abuse, employment instability, antisocial beliefs, and criminal companions). Phase 4 equipping individuals with the skills, values, attitudes, and resources necessary to lead a different kind of life that is highly valued by each individual and one that does not involve inflicting harm on themselves. Phase 5 goal attainment and to monitor progress via regular supervision.

Evidence for the GLM Specific to Offenders?
Harkins, Flak, Beech & Woodhams (2012) 76 men who participated in GLM based community SO treatment 701 who participated in an RP oriented treatment

Evidence for GLM Harkins et al.(2012) (con’t)
pre-post treatment psychometric assessment – measures which previous research demonstrated associated with recidivism Attrition rates Facilitators perception of the program and offender’s motivation Offender’s perception of the program

Attrition rates did not differ significantly No difference in rates of change on psychometric measures Facilitators liked the GLM-based module 63.7% did not think it would be appropriate for high-risk/unmotivated clients

Clients rating of improved understanding of their offending - 80% of RP group compared to 46% GLM better understanding of the positive aspects of themselves 61% for GLM compared to 20% for RP

Rating re: changing thoughts and attitudes in a way that they were better able to manage themselves or their reoffending 80% for RP, vs. 27% for the GLM module thoughts and attitudes about themselves or the future were more positive - 47% for GLM vs. 20% for the RP module.

Evidence for GLM Harkins et al.(2012) (con’t) Summary
GLM module led to offenders who feel better about themselves and their future, however did not improve their awareness of risk factors and self-management strategies Opposite was true for RP/RNR based program no differences overall in terms of attrition or change on risk factors Noted that more recent revisions of the module include greater focus on risk factors

GLM vs. RNR Does GLM say anything that RNR does not?
GLM: Criminal behaviour arises from an attempt to relieve a sense of incompetence, conflict, or dissatisfaction that arises from not achieving valued human goods RNR approach: crime results when the personal, interpersonal, and community supports for behavior are favorable to crime

GLM vs. RNR RNR focuses on the Central Eight -addressing such needs as lack of education and employment and lack of supportive, rewarding, and prosocial familial and marital relationships GLM identifies 9 “goods” with a great deal of overlap with the Central eight

GLM vs. RNR GLM goods RNR Central Eight Knowledge
Excellence in Play and Work Autonomy Inner peace Relatedness/ Community Spirituality Happiness/Creativity Schooling/Employment Employment/leisure Employment/cognitions/ attitudes Antisocial cognitions; antisocial personality pattern Associations/Family marital Antisocial attitudes Leisure/work/family/ associates Autonomy = the desire to formulate ones goals and seek ways to realize them without undue interference seeking employment, financial independence, assertion Inner peace – emotional regulation, positive relationships Happiness/creativity related to doing things that you enjoysuch as sports, sex

GLM vs. RNR Both models discuss the importance of acquiring skills
Ward et al. claim that the GLM addresses criminogenic needs by building strengths and being positively oriented Andrews & Bonta(2010) discuss the importance of prosocial skills building and role-modeling by treatment providers

GLM vs. RNR Wormith, Gendreau & Bonta (2012) - some of the professed shortcomings of RNR and alleged differences between RNR and GLM are illusory. E.g., the difference between addressing deficits and building strengths. From a practical field-level perspective, the difference is mostly semantic But in reality RNR focuses on skill building and attitude change in order to address the criminogenic need much as GLM does

GLM vs. RNR The need to use approach goals and positive language is a contribution – field too often focused on negative No evidence this leads to greater benefit from treatment But in reality RNR focuses on skill building and attitude change in order to address the criminogenic need much as GLM does

RTC Sex Offender Program
Triage Process What do I mean by High Risk/Needs RTC program

Triage Process in Ontario
RTCSOTP in operation from 1972 to 2011 Only institutional sex offender program in Ontario until 1989 WSBC initiated at that time 1992 Sex Offender Assessment Team established at the Millhaven Assessment Unit

MAU Assessment MAU Sex Offender Assessment team assesses all sex offenders entering the Federal prison system in Ontario In Canada sentence 2+ years served Federally Assessment addresses level of risk (actuarial) and treatment needs

MAU Assessment (con’t)
Initially used PCL-R, SORAG, LSI-R, RRASOR and case history added Static-99/STABLE when available Dropped PCL-R/SORAG in 2002

MAU Assessment (con’t)
developed first National Standards for sex offender treatment established Low, Moderate and High Intensity designations

Intensity Levels With Standards we (i.e., regional sex offender program directors) adopted these levels of intensity RTCSOTP=high WSBC=moderate Bath (est. ~ 1992) low-moderate late 1995 RTCSOTP focus on high risk, high treatment needs offenders

Intensity Levels Risk/Needs defined according to RNR principles:
Risk assessed actuarially Need defined in terms of established criminogenic needs (intimacy deficits, attitudes, deviant arousal, problem solving, social competence, etc.)

Moderate WSBC HISOP RTC** MAU
**Low Pittsburgh Low-Mod Bath Note Low intensity program discontinued 2010, RTC program discontinued in 2011 Now the Moderate and High programs are both instutionally based

RTC Sexual Offender Treatment Program

RTCSOTP Description of the Clientele Program Components Outcome data

Actuarial Risk This table shows the scores on various actuarial risk assessment tools for RTC sex offenders compared to the data reported by Calvin Langton, in his PhD thesis, for men assessed for the WSBC. As can be seen, the RTC guys score higher, by about 1 sd, on every measure. As a further comparison, the average score for RTC offenders on the VRAG is at the 76th percentile for the norms published by Quinsey et al (1998). The SORAG score is the 80th percentile.

Changes over Time This slide shows the changes over time in terms of scores on the actuarial instruments. As can be seen, comparing more recent admissions, after the focus on high risk/needs offenders occurred, to those assessed in the early 90’s, a much higher percentage of offenders fall into the high risk category. The PCL-R high risk refers to total scores over 29. Using a cut-off of 25, 49% of our clients are in the high-risk range.

Program Differences Note: aHi intensity differs from Moderate
Hi Mod Lo-Mod Lo LSI-R b 25.1 21.9 17.3 10.3 Static-99a 5.9 4.1 2.9 1.6 STABLEa 9.5 7.0 4.8 3.5 Note: aHi intensity differs from Moderate bHi intensity same as moderate but different from other groups

Diagnosis Finally, use DSM diagnoses to determine the presence of increased responsivity needs looked at 48 consecutive admissions to the SOTP (in 2005) 37 (77.1%) meet criteria for a personality disorder 15/37 (40.5%) have personality orders described as “severe” by the diagnostician (e.g., BPD, Narcissistic, psychopathy)

Diagnosis (con’t) Behaviours resulting from these PD’s lead to management difficulties in their parent institution, including long-term segregation (15, or 31%) 16/48 (31.3%) suffer from mood disorder (Depression, Bipolar Disorder) 10 (28%) suffer from psychosis

Diagnosis (con’t) 22 (45.9%) met the criteria for a paraphilia, most often sexual sadism or pedophilia Nine of these 22 (41%) also meet criteria for severe personality disorder – typically psychopathy or borderline

Deviant Arousal Every admission to our program assessed via PPG
Men with child victim audio child sexual violence assessment (Quinsey & Chaplin, 1988) Men with adult victims adult sexual violence assessment (Quinsey, Chaplin & Varney, 1981) Used to use slide assessment up to about 2001 but dropped it

Deviant Arousal 40% of adult rapists deviance on adult sexual violence assessment 92% of child molesters deviant on child sexual violence assessment 24% of sample (n=657) non-responders Used to use slide assessment up to about 2001 but dropped it

RTC Sex Offender Treatment Program
Designed to be delivered over ~7 months 13-session intro module then Two primary components Self Management – Disclosure; Cognitive Distortions; Emotions Management; Development of Behavioural Progression; Development of Self Management Plan Social Skills – Communication Skills; Goal Setting; Problem Solving; Empathy; Assertiveness; Relationships

RTC Sex Offender Treatment Program
4-5 group sessions per week (ideally 4) and one individual therapy session Either alternate between Self Management and Social skills sessions (if two different delivery teams) or alternate modules In addition milieu therapy – program staff interacting with offenders in unstructured manner on living unit Milieu – allows observation/role modeling in natural environment – . Program staff spend part of each day on the living unit interacting with clients. Occasionally issues associated with treatment are discussed in this context but such interactions also allow staff to be involved in interpersonal interactions among the clients. These interactions give staff an opportunity to intervene and model appropriate problem solving, social interaction skills and conflict resolution in a “real time” context. As well, these interactions also provide staff with an opportunity to observe the behaviour of clients when not in treatment. We believe that clients (particularly psychopathic clients) can succeed in manipulating staff for the two or three hours a day that they are in group. However, they are, from our experience, less able to manipulate well trained staff when their behaviour is monitored 24 hours a day seven days a week. Those clients who are not actively engaged in treatment generally demonstrate inappropriate behaviours on an ongoing basis when not in group.

Program Delivery Schedule
Monday Tuesday Wednesday Thursday Friday AM Self-Management B Group PM Self-Management A&B groups Social Skills A&B groups Social Skills A Group Self-Management A Group/Social Skills B Group 2 groups running concurrently

Program Structure Related to Criminogenic Needs
Treatment components Antisocial Associates/Negative Social Influences Social Skills/ Milieu Antisocial cognitions/Offence Supportive Attitudes/emotional congruence with Children /Resistance to Rule/Supervision Cognitive Distortions/ Individual Therapy/Social Skills/Milieu Antisocial Personality Pattern /Lifestyle Impulsiveness Cognitive Distortions/ Emotions Management /Individual Therapy Criminogenic needs – the central 8, the CN identified by Mann et al. and the needs associated with psychopathy identified by Wong and Hare

Treatment components Substance Abuse Emotions Management /Individual therapy Family/Marital problems/Lack of emotionally intimate relationships with adults Social Skills / Milieu School-work Leisure/recreation Social Skills/ Self-Management /Milieu

Treatment components Sexual Preoccupation Emotions Management /Relationships/ Individual Therapy Sexual Deviance Arousal Management/ Emotions management/ Individual Poor Problem solving Problem Solving Hostility/dysfunctional emotions Emotions management / Individual therapy

Treatment Components Wong & Hare (2005) identify as treatment targets for psychopathic offenders Dysfunctional attitudes and behaviors Dysfunctional emotions and lack of emotional control Failure to accept responsibility for their own actions Substance abuse Lack of work ethic, employable skills and appropriate leisure activities Antisocial peers, networks and subculture Note that these targets correspond to Andrews & Bonta’s bi g 8 risk factors\ Each of these targets is addressed in the RTCSOTP components + deviant sexual interests

Introductory Module Introduces offender to the program
Group rules (arrived at through group discussion) Treatment concepts/Jargon (CBT, Offence Chain etc.) CBT – the idea that thoughts and behavior are related new to clients Examples to illustrate Key word here Realistic – what is realistic for the offender – low education, no or few job skills

Introductory Module “goof”  need to fight
“I need to retaliate otherwise people will think they can push me around” “I don’t think – I just react” Is this a bad word in NY prisons? What happens when you hear this word? Why? So what do you think when you hear this?

Introductory Module “I need to retaliate otherwise people will think they can push me around” But isn’t this a thought

Introductory Module Motivational Issues
Psychopathic clients often poorly motivated to change Motivation to change typically self-focus (get out of prison – “good report”) Work with what you’ve got First sessions focused on motivation/goal setting – finding reason for change

Introductory Module Process of change How we begin the change process
Cost-benefit analysis of changing Possible selves – how do you see yourself after you’ve completed the program Realistic expectations for the future Key word here Realistic – what is realistic for the offender – low education, no or few job skills

Change Process Have offender identify a role model
“Can you name anybody from your life who is not a criminal that you might use as a role model?” Old me /New me homework

Old Me New Me Old Me What would you like to change about your personality and how you act? What strengths do you have that will help you to make these changes? New Me Based on these changes what do you think the new me will be like? What goals do you have for yourself in this program?

Treatment Motivation/Goal Setting
Importance of setting goals SMART principle S = SPECIFIC M= MEASURABLE A= ACHIEVABLE R= REALISTIC T= TIME LIMITED Require them to set some goals for the program and monitor progress S = SPECIFIC: a goal is something specific that you want to do, get or achieve. For example, “I will not fight with people” is less specific than “I will learn to stand up for myself without becoming angry.” M= MEASURABLE: how will you know when you have reached your goal? You must be able to see the results of your goal being met. Your goal must be something that can be assessed in a way that you will know whether or not it was achieved. For example, “I will get in better shape” is not measurable. However, “I will lose twenty pounds by this time next year” would be an example of a measurable goal. A= ACHIEVABLE: your goal must be challenging, yet achievable for you. R= REALISTIC: It may take some time to reach your goal but it must be realistic. T= TIME LIMITED: It is crucial to have a timeframe in mind for achieving your goal.

Introductory Module- Consent
Discussion early on in program to start offenders thinking about issues of consent What is consent Conditions necessary for consent have to be willing to have sex have to be able to understand possible consequences of consenting e.g. STDs, pregnancy need to be sober Must be of age

Introductory Module- Consent
Consent negotiated Reasons for age of consent Legal age vs. age appropriate Consent scenarios Notion that consent is negotiated means that what is going to happen is actually discussed to some extent

Consent Scenarios 1. You are in a bar and you are getting along well with a woman who seems quite interested in you. However, you realize that she looks quite young -although it is certainly possible that she is 19 years old. What do you do? 2. Your 13 year old step-daughter comes into the room in a see-through night gown and cuddles up to you on the couch. No one else is home. Is she indicating that she is sexually interested in you?

Consent Scenarios 3. You have met the same woman at the bar you like to go to several times before. Tonight things have become very friendly and you think that she really likes you. At closing time you ask her back to your place for a drink. She accepts. What would you do from here? 4. Same situation as above except that you have been “fooling around” (i.e., kissing and caressing each other) while at the bar. At closing you ask her if she would like to “continue this at your place” - she accepts. Do you have consent? Consent for what?

Sex and the Media Discussion of the effects of media on sexual attitudes and behavior foster skills necessary to exercise responsible and healthy personal choices in using media pornography = any media that promotes unhealthy beliefs about sexuality, exploits sexuality for commercial purposes, or is sexually degrading. degrading towards both women and men Idea here is that in the real world the offenders will be exposed to sexually oriented media and they need to be prepared to deal with it – Degrading to both women and men in that it exploits male myths and widespread beliefs about male sexuality.

Sex and the Media media that is legal can be used for unhealthy purposes. use legal pornography to prime deviant fantasies. possible to use material that is not usually thought of as pornography to prime deviant fantasies. E.g. TV shows, movies, commercials or magazine ads Rock paper scissors billboard - Toddlers in tiaras

Autobiography and Disclosure

AB & Disclosure AB outline handed out during the second intro session
Given specific deadline (i.e., first disclosure will occur…) Meet with therapist a couple of times to discuss and track progress Less than 10 pages too short, more than 30 too long

AB & Disclosure includes information regarding times in their lives where they have engaged in criminal behaviour also periods where they have managed to remain crime free. What was going on when things were going well vs. when things were going poorly

AB & Disclosure Disclosure – one session per offender
30-45 minutes presentation, break then questions ~ 30 minutes Content of disclosure brief personal background Relationship history Offences – but no specific detail We want to know age and sex of victim – how victim was chosen/groomed etc. but not specific of the sexual assault – those are discussed individually

AB & Disclosure Questioning – by all group members Clarification
Supportive challenging of minimization/denial Not confrontational – Marshall, Marshall, Serran & O’Brien (2011) – therapists who present as warm, empathic, rewarding and directive, but not confrontational most effective Cite research which indicates that therapists who were rated as confrontational by clients were less effective - clients more likely to withdraw from treatment if therapist rated as confrontational less skilled Important to remember the goal of the disclosure – 1) to elicit information about offender’s thinking re: his offending; 2) to assist with the development of a behavioural progression; 3) increase accountablity

AB & Disclosure Goal of these exercises/sessions to increase accountability/openness about offending/sexual deviance NOT looking for the “truth” Official version not the true version of events Trauma effects recall Reconstructive nature of memory Important to remember the goal of the disclosure – 1) to elicit information about offender’s thinking re: his offending; 2) to assist with the development of a behavioural progression; 3) increase accountablity Impossible to determine what the truth is – lots of evidence to suggest that the Official version will contain inaccuracies – trauma affects ability to remember, reconstructive nature of memory Expect the truth to be somewhere between offical version and offender version Therefore expectation is a plausible explanation of offence that does not include victim blaming and that acknowledges impact

AB & Disclosure DO NOT expect offender’s account to match the official version plausible explanation of offence that does not include victim blaming and that acknowledges impact Is this approach effective in terms of increasing accountability? Important to remember the goal of the disclosure – 1) to elicit information about offender’s thinking re: his offending; 2) to assist with the development of a behavioural progression; 3) increase accountablity Impossible to determine what the truth is – lots of evidence to suggest that the Official version will contain inaccuracies – trauma affects ability to remember, reconstructive nature of memory Expect the truth to be somewhere between offical version and offender version Therefore expectation is a plausible explanation of offence that does not include victim blaming and that acknowledges impact

Columns don’t add to 100% because intermediate group is not displayed e.g. denial of facts pre- other 43% somewhere between full denial and no denail Can see that the number of offenders denying facts decreased from 26% to about 5% Denial of victim harm from almost 50% to about 10% Denial of responsibility from 55% to 15% Notice that some categories Planning, responsibility have relatively high rates post – will come back to this in a moment

AB & Disclosure Calculate a scale for total denial score in which low scores indicate greater denial

AB & Disclosure Slight nonsignficant tendency for men discharged from treatment to deny E.g. 36% of discharged deny facts pretreatment compared to 26% of completers

AB & Disclosure Who gets discharged? attrition table.rtf
only disruptive behavior predicts discharge

130 offenders overall Looking here at the row Static 6+ Denial throughout – 38.9% recidivism – higher than all other groups Note also that for the moderate risk offenders no denial led to slightly higher recidivism – although non-significant. Get back to that in a minute. N low stat denial through -

Denial of Impact – full acknowledgement 8.14 2 .017
B SE Wald df p Exp B Static-99R .100 .043 6.65 1 .036 1.09 Denial of Impact – full acknowledgement 8.14 2 .017 Denial Of Impact – some acknowledgement -.87 .307 7.99 .005 .420 Denial of impact – no acknowledgement -.27 .203 1.72 .190 .767 Denial of sexual motivation – acknowledgment 10.84 .004 Denial of sexual motivation – some acknowledgement .77 .274 7.62 .006 2.128 Denial of sexual motivation – no acknowledgment .69 .292 5.564 .018 1.993 Types of denial – post treatment Note that the direction of the relationship between reoffending and the two types of denial are opposite. Denial of impact the direction is the more denial the lower recidivism while denial of sexual motivation is more denial greater probability of recidivism.

Cognitive Distortions
Cognitive distortions component Focus on becoming aware of distorted thinking Both generally criminal and associated with sexual offending Challenging cognitive distortions without being confrontational. Use the group process Address common distortions related to both general criminal behavior and sexual criminal behaviour – use the group process to assist with this Encourage group members to point out distortions in each others thinking

What information has the client previously provided which is contradictory to the distortion? What is the evidence for the thought? Remain neutral.

Use of ACT model to challenge distortions Awareness of distorted thinking. Choose to think rationally (what is true, what is not). Take action - Replace with appropriate thoughts.

Important notion re: cognitive distortions is the idea of excuse making Mann & Maruna (2006; Mann & Ware, 2012) – normal human tendency toward excuse making excuse making is “the process of shifting causal attributions for negative personal outcomes from sources that are relatively more central to the person’s sense of self to sources that are relatively less central” p. 156 It’s not my fault because….

‘fundamental attribution error’ … many of the rationalizations and minimizations offered by offenders may be situational rather than dispositional. “When challenged about having done something wrong, all of us reasonably account for our own actions as being influenced by multiple, external and internal factors. Yet, we pathologize [offenders] for doing the same thing.” p. 158 Mann & Maruna argue that the labelling of distortions as something negative that have to be challenged and changed in treatment is akin to the fundamental attitubution error Fundament attribution error: tendency to over-value dispositional or personality-based explanations for the observed behaviors of others while under-valuing situational explanations for those behaviors. The fundamental attribution error is most visible when people explain the behavior of others. It does not explain interpretations of one's own behavior—where situational factors are often taken into consideration. This discrepancy is called the actor–observer bias.

No win situation: “If they make excuses for what they did, they are deemed to be criminal types who engage in criminal thinking. If, however, they were to take full responsibility for their offences – claiming they committed some awful offence purely ‘because they wanted to’ and because that is the ‘type of person’ they are – then they are, by definition, criminal types as well.” p. 158

Zuckerman (1979) – people make predominantly external attributions for our failures and predominantly internal attributions for our successes. Argue that we need to be more sophisticated in our approach to cog. Distortions So offenders aren’t that different from everyone else

excuse making is a highly adaptive mechanism for coping with stress, relieving anxiety and maintaining self-esteem. Those who assume full responsibility for their failings put themselves at risk of suffering depression.

‘revised helplessness theory’ (Abramson, Seligman, and Teasdale,1978) individuals who have an explanatory style that invokes internal, stable and global attributions for negative life events (and external, unstable and specific attributions for positive events) will be most at risk when faced with unfortunate circumstances, such as the loss of a job or a relationship breakup.

Hanson & Morton-Bourgon (2004) no relationship between denial of sex crime or minimizing responsibility and recidivism However more recent research has shown that there is a relationship between denial and recidivism for some offenders

Also note that there is no evidence to support the notion that cognitive distortions (as distinct from offence supportive attitudes) predict recidivism

So going back to this slide – denial of responsibility and denial of planning can be seen as excuse-making vs. offence related attitudes Notice that some categories Planning, responsibility have relatively high rates post – will come back to this in a moment

Denial of Impact – full acknowledgement 8.14 2 .017
B SE Wald df p Exp B Static-99R .100 .043 6.65 1 .036 1.09 Denial of Impact – full acknowledgement 8.14 2 .017 Denial Of Impact – some acknowledgement -.87 .307 7.99 .005 .420 Denial of impact – no acknowledgement -.27 .203 1.72 .190 .767 Denial of sexual motivation – acknowledgment 10.84 .004 Denial of sexual motivation – some acknowledgement .77 .274 7.62 .006 2.128 Denial of sexual motivation – no acknowledgment .69 .292 5.564 .018 1.993 This slide here denial of impact = “it wasn’t so bad” – post hoc excuse making vs. offence supportive Denial of sexual motivation - Child molesters – I was just trying to be her friend

it could be that offenders attempting to rationalise their deviant behaviour may exhibit other low-risk characteristics and feel a need to justify their atypical behaviour, whereas offenders admitting their deviant actions may see no need to justify behaviour that is consistent with their internal representations of self. Important to remember the goal of the disclosure – 1) to elicit information about offender’s thinking re: his offending; 2) to assist with the development of a behavioural progression; 3) increase accountablity Impossible to determine what the truth is – lots of evidence to suggest that the Official version will contain inaccuracies – trauma affects ability to remember, reconstructive nature of memory Expect the truth to be somewhere between offical version and offender version Therefore expectation is a plausible explanation of offence that does not include victim blaming and that acknowledges impact

Cognitive Distortions that Impede Empathy Do not have victim empathy/empathy training component Mann et al. (2011) – victim empathy not associated with recidivism Marshall et al. – empathy deficits are victim specific rather then generalized We don’t do letters taking responsibility – don’t do roleplays etc

Instead discuss cognitive distortions that impede empathy View videos to illustrate victim impact Discuss specific distortions used to shut down empathy Distorted thinking allows offenders to shut off empathy for victim at time of offence

Attitudes Discussion of helpful vs. harmful attitudes
How do we know? How do positive attitudes affect our behaviour?

Attitudes Mr. Brown was released from prison two weeks ago and has been looking for a job. He has circled yet another ad and is on his way to another interview. He has been rejected four times even though he feels that he is well qualified to do each job. Here is an example of what he is saying to himself, "I don't know why I'm even bothering to see the boss. I've never been able to get a good job before. I'm just a fucking failure, an ex-con. I have no money left and I won't lower myself to get welfare. I won't be able to pay the rent and I'll be kicked out of my apartment. If I don't get this job, I might as well just go back to jail. I knew I'd never make it. I might as well use the rest of my money and get drunk."

Attitudes "Why will he never be able to get a good job?"
"What does Mr. Brown define as a failure?" "Is getting a job the only way to define success and failure?" "If there is no money left, are there other sources of money?" "Why is getting welfare more problematic than going back to jail?" "Is getting drunk a good coping strategy?" "What can it lead to?" Questions to ask to generate discussion

Attitudes Identify the negative attitudes expressed
which positive attitudes could be substituted How can these attitudes affect reintegration and relapse. Identify attitudes related to areas such as self worth, success, using support, attitudes towards change, etc. and how these relate to thoughts, feelings and behaviours

Emotions Management Component
Addresses coping with difficult emotional states – loneliness, jealousy, depression etc. Cognitive strategies – self-talk, challenging distortions Behavioural strategies – relaxation Acceptance of negative emotions

Emotions Management Awareness of emotions – how do we know what we are feeling? Bodily signals Self talk Self monitoring homework Discussion of various “high risk” emotions Sadness, anxiety, anger, hostility, loneliness, shame/guilt, self pity How do these emptions differ from each other in terms of the cogntiion, physical sensations which accompany them

Emotions Management Also discuss positive emotions which may place someone at risk Distorted cognitions which accompany feelings of happiness related to success/accomplishment Link these emotions to behavioural progression e.g. just got a raise at work, need to go out and celebrate Baseball team won the tournament

Emotions Management Anger Discussion of role of anger
It is a “normal” emotion can be helpful Cognitive and physical signals related to anger Addressing cognitive distortions that lead to anger

Anger Emotions Management
Rating anger on a scale of 1-10 rather than using emotionally based language. What does “anger 7” look like? Why is this important? Anger funnel discussion.

Anger Funnel Loneliness Boredom Disappointment Sadness jealousy ANGER

Emotions Management When Is Anger A Problem? When it is too frequent.
When it is too intense. When it lasts too long. When it leads to aggression. When it disturbs work or relationships. When it is unresolved. When it hurts others. When it is sexualized.

Emotions Management Strategies for managing emotions
Assertion vs. aggression Self-talk Relaxation/mediation/mindfulness Effective communication

Emotions Management Sexual arousal
Discussion the notion that sexual arousal is a feeling Can be managed like other feeling Don’t need to act on it Same strategies apply Discussion of arousal management strategies In group keep conversation general – not specific discussion of fantasy content

Arousal Management Individual therapy sessions
Every offender discussion of fantasy and how it relates to offences Sexual fantasy monitoring discussion of specific role fantasy plays in life/offending (e.g., sex as coping) social skills training, strategies to deal with negative emotionality (e.g., anger, depression)

Arousal Management Fantasy/arousal modification Covert sensitization
develop fantasy scripts – deviant and appropriate Develop strategies for controlling arousal In lab – monitor arousal while reciting script Use strategies to diminish arousal – then use appropriate fantasy to generate arousal If not successful refer to psychiatrist Strategies – preference to be focusing on victim harm – learned that in the cog distortions component Some offenders doesn’t work  harm/embaressment to self

Behavioural Progression
Different ways of doing BP – e.g. Yates Kingston & Ward (2010) Prefer simple Series of thoughts, feelings and behaviours which culminate in sexual offence Clients to identify 7-10 such sequences If multiple offences chose “typical” offence

OFFENCE CHAIN EXAMPLE.docx 4 wife chain.docx approach goal.docx approach chain.docx

Also ask for distal factors related to offending Background factors Abuse Substance abuse Relationship problems Present to group Constructive feedback

Social Skills Component

Majority of high risk/needs clients lack in basic social skills Risk factors Antisocial peers, networks and subculture Loneliness, lack of prosocial relationships, poor job prospects, intimacy Focusing on enhancing skills to develop/maintain prosocial relationships Heavily focused on skill-building Lack of social skills related to risk factor of antisocial peers etc. Use of role-plays in most sessions

Values identification Serves as basis for much of discussion in coming components What are my values? making decisions, solving problems and communicating with others. Decisions that support our values enhance our ability to solve problems and help us live pro-social lives

Communication Skills – oriented toward developing appropriate relationships Replacing aggressive communication (which has likely been reinforcing for the client in the past) with listening skills and active listening Emphasis on costs and benefits of aggressive communication (decision matrix) Notice that as we go through the various components the self-management component and the social skills component complement each other in terms of the content and skills

Problem solving/Assertiveness Recognize when they are facing a problem and develop appropriate strategies to cope (as opposed to substance abuse, violence and sex) Skills allow them to maintain supportive relationships and end inappropriate one Help them to keep jobs

Relationship Skills: Emotions matter even if they are difficult to figure out. At least need to understand that they matter to other people and be able to differentiate basic emotions. Dealing with jealousy Negotiating consent How to chose a partner Avoiding impersonal sex

Disclosing criminal history to partner
Relationship Skills Disclosing criminal history to partner Role play Privacy circle discussion Describes the development of relationships From stranger to intimate relationships develop 3-date rule

Relationship Skills Purple - You
This is the center of the circles and you are the only person in this circle. This means that you are the most important person in your world and you are the center of your circles. Where people are placed in the circles depends on your relationship with the person. Blue - Intimates This is the second circle and is the circle that is closest to you. It has people who are close to you. This circle usually has your mother and father and possibly a girlfriend or boyfriend in it. Green - Friends This circle includes people that you have less physical contact with than people in your blue circle. You may hug these people but only on special occasions and the hug only lasts a short time. This circle may include family members and close friends that you really like spending time with. Yellow - Acquaintances This circle includes people that you shake hands with. This may include acquaintances and other people you know. These are people that you do not have an emotional bond with and you have very little physical contact with them. ORANGE – casual acquaintance This circle includes the people where you know their name but that may be all that you know about them. You do not know these people very much. You do not have any physical contact or emotional bond with these people. This may include casual acquaintances, neighbours, and children. YOU SHOULD ALWAYS PUT CHILDREN YOU KNOW IN THIS CIRCLE. Red- STRANGER This circle holds two different types of people: Strangers: these are people that you do not know and you should not have any type of contact with them. You do not touch them or speak to them. The community helper: these are people who have a job where they are there to help you. You do not know these people but you talk to them because of their job (for example: police, nurses, doctors, dentists, parole officers, social workers). If these people touch you it is only to do their job. You should not touch these people.

Relationship Skills Ideal Partner – asked to describe in terms of: Appearance, Attitudes, Education, Career, Personality traits, interests/hobbies, Religion, Cultural background, Rank importance - 1 to 8 Is their ideal partner consistent with the values they identified earlier? Don’t go from first meeting to moving in in a day  "How does your "Ideal Partner" compare to what you want out of a relationship?"  "How does your "Ideal Partner" compare with the partners you have chosen in the past?“ Typically looking for rather pro-social things in relationships – nobody says I'm looking for a drug addicted prostitute with missing teeth Most of the time real partners will not match up to ideal partner - how realistic are their expectations

Relationship Skills What do they bring to the relationship – what can they offer Often expect more from a partner than they themselves are able to give. Lead to discussion of re-evaluating what their expectations of a relationship are – idea of compromise Again – how realistic are their expectations Facilitators will lead the discussion by stating that now that many of you have realized that your goals may not be met, what do you think you can do to change this? Responses may include:  Change your goals  Lower your expectations  Re-evaluate the things that are important in a partner 6. Facilitators can point out that clients may need to compromise in order to attain their goals:  "Looking at your "ideal partner", what are you prepared to compromise?"  "Can you live comfortably with these compromises?"  "If you are not happy with these compromises, then this could cause problems in the relationship in the future."

Relationship Skills Maintaining Relationships
Relationships require work Face strain from change – children, job loss Other relationships – in-laws Show respect Be honest and truthful Do little things to show you care Treat your partner as an equal Take equal responsibility Make time (for family, for partner, for yourself) Be open to change Maintain individuality/respect individuality of partner Again – how realistic are their expectations Facilitators will lead the discussion by stating that now that many of you have realized that your goals may not be met, what do you think you can do to change this? Responses may include:  Change your goals  Lower your expectations  Re-evaluate the things that are important in a partner 6. Facilitators can point out that clients may need to compromise in order to attain their goals:  "Looking at your "ideal partner", what are you prepared to compromise?"  "Can you live comfortably with these compromises?"  "If you are not happy with these compromises, then this could cause problems in the relationship in the future."

Relationship Skills Coping with loneliness, rejection and jealousy
Being alone vs. loneliness What does it mean to “be alone” Advantages of not having a partner Rejection – what does it mean when someone rejects you? Possible reasons for rejection Ways to cope Complements emotions management component Rejection – Reactions for being rejected – feeling hurt, feeling angry etc. Why might someone reject you – mannerisims, behaviours (drinking, drug use, aggression) personal issues of their own personalizing, overgeneralizing go back to the cog. Distortions component – how to deal with this sort of thinking

Relationship Skills Coping with loneliness, rejection and jealousy
Jealousy – what is jealousy and why do we feel it When you don't feel good about yourself When you are dependent on your partner for your happiness When you don't enjoy spending time alone When you lack social skills When your expectations aren't being met When you've made the wrong partner choice Lacking social skills – communication, assertiveness etc.

Relationship Skills Coping with jealousy
Try to determine if the jealousy is based on fact or fear Communicate your feelings to your partner in the very beginning Don't allow negative self-talk to get out of hand Negotiate with your partner ways to avoid situations that perpetuate the jealousy Seek counselling These task obviously require advance social skills – communication, assertiveness etc.

Self Management Component

Self Management Puts everything from program together
Remind themselves of goals/reasons for change Identify risk factors and main coping strategies Relapse Cues Appropriate use of leisure time Main sources of support Present/discuss in group Risk factors People, places, things

Individual therapy component

Address issues unique to the individual not addressed in group Follow-up on issues which come up in group Assist with homework Arousal work

Substance Abuse CSC has comprehensive substance abuse programming therefore do not target directly in SOTP Discuss role substance abuse plans in offence progression Importance of avoiding substance abuse in risk management/prosocial lifestyle Don’t mix substance use and sex

Individual Therapy Importance of rapport.
Understanding that treatment with such clients is a long term undertaking. Prepare offender for dealing with the lapses that WILL occur Drug use Fighting Angry outbursts

Individual Therapy Manipulative Behaviours
Need to keep perspective in that these can be expected with High PCL-R clients. Need for team communication. Meetings with the client and all those involved in manipulative communications. That way everyone hears the same thing Behavioral contracts . What is the client really after-Is it a reasonable request? Sometimes what some staff see as manipulative/demanding is actually a reasonable request. e.g. johnson and BMR based on other offender’s say so

Program Referrals RTC WSBC Maintenance Bath SOP
The other Possibility is that after completing the RTC they simply are released Bath SOP

Treatment Outcome Note: 6+ group average PCL-R score about 25, 22% over 30

Treatment Outcome

Treatment Outcome Sexual Recidivism for men with PCL-R scores over 25 AND Static-99 over 5 n=70 follow-up 4.5 years 15.7% new sexual conviction psychometric table.docx

% Any Violent recidivism
Treatment Outcome % Sexual Recidivism % Any Violent recidivism RTC only (n=152) 11.8 24.3 RTC + Mod (n=24) 8.3 12.5 RTC+ Mod + Maintenance (n=11) Over 7-year follow-up N’s small but data suggests that adding the moderate programming and maintenance  decreases in recidivism Moderate program typically not another full program, but targetted toward addressing outstanding needs

Community Treatment & Supervision

Community Supervision
Community treatment of high risk sexual offenders picks up where institutional treatment ends. The aim of community treatment is not to discuss the same material as was covered in institutional treatment programs. The goal is to apply the knowledge which offenders have gained in institutional tx. to community settings.

For example, institutional treatment programs typically focus on intimacy deficits as one aspect of dynamic criminogenic risk. Institutional programs may teach the offenders some of the communication skills, skills related to dealing with jealousy, knowledge of sexuality that will increase the odds of these clients being able to establish and maintain intimate relationships.

However, it is not until these clients enter the community that the majority may have the opportunity to use these skills in developing a relationship. Issues such as disclosure of offense history, overnight visits and having the partner meet with correctional staff all need to be addressed.

Specific Challenges with High Risk Offenders
Manipulative behaviors Need for frequent contact with team members involved in management of the case. Control of living environment. Checks with employers at worksite/via phone. Meeting with partners of offenders. Consequences of inappropriate behaviors discussed. When possible, suspension is avoided.

Consequences of inappropriate behaviors discussed. Where possible these are discussed as opportunities to learn (e.g., thinking that you can put yourself in high risk situations). Aggressive Behaviors: Fighting is clearly not permitted and almost always results in suspension. Threatening and aggressive communication is discussed in sessions and contributing factors addressed.

Particularly with high risk offenders, there is the need to watch for them falling into old patterns of behavior (e.g., lying about their offence history to a prospective partner, simply not informing correctional staff about the fact that they are dating someone). We put few constraints on who sex offenders can date with exception to child molesters being involved in relationships with those who have children.

General Guidelines For high risk offenders it is best that they be housed in a Community Correctional Centre (CCC) or equivalent. These settings offer offenders with few means of support a place to live and provide enough money for basic needs. Offenders must sleep at the CCC unless authorized in writing to stay elsewhere. Team Supervision Unit (TSU) as another option.

General Guidelines If possible, parole officers and psychology staff should be housed within the same building. In the Toronto area all sex offenders must be assessed for treatment by staff in the psychology department. It is assumed that, except in rare circumstances, all offenders with a recent sexual offence conviction will attend one of several sex offender specific treatment programs.

General Guidelines Having psychology in the same building as CCC/TSU makes it easier for those who are only allowed limited access to the community to attend treatment. Meetings between parole officers, psychology staff, parole supervisors occur on a regular basis. STABLE 2007 is scored on offenders on a yearly basis/STATIC-99/99R is scored if not available on file Individual therapy and/or group treatment are available.

Sex Offender Maintenance Treatment Program-Central District
Clients attend treatment until WED. Groups begin with check in. Issues of mutual concern typically arise. Those issues related to criminogenic factors (relationships, high risk situations) receive more attention. Clients are asked to present a synopsis of their behavioral progressions, behavioral management plans to group.

The goal is to keep clients in the community and when suspension is necessary, release them at the earliest possible date. There is a need to compromise with clients on a variety of issues. Context becomes very important in decision making. How has the offender been doing in the community to this point in time. Are we hearing about other difficulties with client from residents at CCC.

Substance Abuse Decision to suspend is client and context dependent. More serious drugs (e.g., opiates) typically result in suspension whereas there is more flexibility with less serious drugs (e.g., THC based drugs). Issues associated with lapses/relapse addressed in detail.

Legal Issues and Impact on Treatment Decisions
In Canada legislation which is similar in principle to sexually violent predator legislation in the U.S. generally falls within two categories: Dangerous Offender (DO) Legislation Long Term Offender (LTSO) Legislation.

Dangerous Offender Legislation
Criteria for DO designation: Demonstrated failure to control sexual impulses There is a likelihood of causing injury, pain, or other evil to other persons in the future Because of the brutal nature of the offence. Typically reserved for offenders with extensive criminal histories. Must be convicted of a serious personal injury offense.

Dangerous Offender Legislation
Between 1977 and 1997 upon finding an offender to be a DO a judge could sentence the offender to either a determinate or indeterminate sentence. In 1997, the law was amended and determinate sentences were removed as a sentencing option. 90% of DOs are sex offenders. 88% have a previous record of incarceration (2001 data used). As of 2001 there were 280 DOs in Canada. Fewer than 10% have been released under parole supervision.

LTSO Legislation-Impact on the Community
To provide an alternative to indeterminate incarceration for some sex offenders who, in the opinion of the court, while exhibiting a substantial risk, could be effectively managed in the community after a period of incarceration lasting two years or more The court may impose a maximum of 10 years of supervision.

The LTSO provisions came into force on August 1, 1997. To date, the 10-year term of supervision is most common. An LTSO does not begin until the offender has completed serving the sentence imposed by the court and any other custodial sentence that may have been imposed.

LTSOs do not begin until after the Warrant Expiry Date (WED) even if the offender is in the community prior to the WED. Some, due to “dead time” end up serving sentences of days/weeks. As a result some of these offenders are released without any treatment having been offered/received in provincial institutions.

Many of these offenders impress as very high needs/high risk. It is very difficult to suspend these offenders for any significant period of time unless there are new charges laid. It is difficult/impossible to offer a high intensity sex offender treatment program in the community.

These offenders present with many treatment needs. In the community they tend to be housed at our CCC or supervised through the Team Supervision Unit (TSU). Coordination with police Frequent team discussions regarding these cases.

LTSO Offenders In Ontario as of 2011 there were 178 men with LTSO
81 were in the community. 18 additional were suspended Most of these are released to one of the CCCs.

Community Treatment Outcome
Followed 25 sex offenders released to Keele CCC in 2007 11/25 LTSO 19 were involved in treatment Of those involved in treatment, none were suspended over an average 3.1 year follow-up. Of the 6 who did not participate in community treatment, 3 were suspended

Community Treatment Outcome
None of these men were convicted of a new sexual offence in the follow-up period Two were convicted for violent non-sexual offences One of these received community treatment

LTSO Offenders These data, which are only preliminary, suggest that even very high risk offenders can be managed effectively in the community using a team based approach. Inpatient housing, at least at first, is typically recommended unless the individual has a prosocial and well developed support network available.

Jan Looman, Ph.D., C.Psych. Kingston, Ontario

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Jan Looman, Ph.D., C.Psych. Kingston, Ontario

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