Treating Youth With Sexual Offending Behavior:

1. Treating Youth With Sexual Offending Behavior: Integrating Clinical Services in a Teaching-Family Model Program Talon Greeff, MMHC Director of Residential Care UTAH YOUTH VILLAGE (801) 272-9980 This training and additional resources can be found at: www.utahparenting.org

2. Introduction “…remember that although the goal when working with juveniles who have committed sex offenses is to help them stop their abusive behaviors, they are children and adolescents first.” -Office of Juvenile Justice and Delinquency Prevention, 2001

3. U.S. Department of Justice, “Juveniles Who Have Sexually Offended - A Review of the Professional Literature” (2001) Network on Juvenile Offending Sexually (NOJOS) Association for the Treatments of Sexual Abusers (ATSA) National Adolescent Perpetrator Network (NAPN) Source Material

4. Outline • Introduction • Hallmarks of Best Practice • Teaching-Family Model Treatment Integration • Treatment of Sexual Behavior Problems (SBP) • Assessment and TFM • TFM Program Treatment Mechanisms • Working with schools • Lessons learned in application of clinical treatment within a TFM program • Suggestions for implementation in a TFM program

5. Utah Youth Village Continuum • Continuum – treatment arc: • Healthy sexuality groups • Intensive outpatient group • Foster care treatment • Group home treatment in a community-based setting

6. Utah Youth Village Continuum • Continuum – treatment arc: • Step-down into foster care and intensive out-patient • Intensive family preservation transitional services

7. Utah Youth Village Continuum • Clinicians initially developed our treatment using current research in treating youth with sexual offending behavior • We have used outside clinicians for youth with these issues in treatment foster care • The Teaching-Family Model works seamlessly and effectively in enhancing clinical treatment addressing sexual offending behavior

8. Hallmarks of Best Practice • National Adolescent Perpetrator Network (1993) suggests that satisfactory treatment requires a minimum of 12 to 24 months • Programs designed to focus exclusively on sex-offending behaviors are of limited value and have recommended a more holistic approach (Goocher, 1994)

9. Hallmarks of Best Practice • Research is lacking on what works best other than it should be “highly structured” and include individual, family and group therapy

10. Hallmarks of Best Practice • Lipsey and Wilson (1998) conducted a meta-analysis of 200 experimental or quasi-experimental studies to assess the effectiveness of treatment interventions used with juvenile offenders • Among non-institutionalized juveniles, treatments that focused on interpersonal skills and used behavioral programs consistently yielded positive effects • Other interventions that have been validated with chronic delinquents, such as multisystemic therapy and multidimensional treatment foster care, also are promising approaches for juveniles who have committed sex offenses (Borduin et al., 1990; Chamberlain and Reid, 1998; Swenson et al., 1998)

11. Hallmarks of Best Practice • Report of the ATSA Task Force on Children with Sexual Behavior Problems (SBP) found that “…incorporating some of these basic SBP elements into evidence-based treatments focused on the highest priority problems may be more feasible than adding or stacking separate therapies”

12. Hallmarks of Best Practice • Social skills and relationships • Research repeatedly documents that juveniles with sexual behavior problems have significant deficits in social competence (Becker, 1990; Knight and Prentky, 1993) • Inadequate social skills, poor peer relationships, and social isolation are among the difficulties identified in these juveniles (Fehrenbach et al., 1986; Katz, 1990; Miner and Crimmins, 1995)

13. TFM Treatment Integration • Provides a flexible, customized approach • Emphasis on skills development to address maladaptive behaviors • Effectively addresses mental health issues and Diagnostic of Statistical Manual (DSM) diagnoses • Integration of clinical treatment for sexually maladaptive sexual behavior

14. TFM Treatment Integration • Treatment providers should receive appropriate training before they begin their work and thereafter on a continuing basis. • Working with juveniles who have sexual behavior problems is a challenging job • NAPN (1993) observed, "Systems must be aware of potential emotional/psychological impacts on providers and take steps to protect against or counter negative effects" (p. 46) • Consultation provides this support to both the TFM practitioners but also to the clinicians • Clinicians receive one hour of consultation services weekly with a supervisor trained in the TFM

15. TFM Treatment Integration • Teaching-Family Model programs meet these expectations: • Individualized - The literature clearly supports the importance of interventions that are tailored to the individual juvenile • Strength-based - risk management most effective in programs which address needs underlying a juvenile's behavior emphasizing strengths and positive supports

16. TFM Treatment Integration • Research-based and empirical - Although efficacy has not been established for many sex offender interventions considered standard and required, there are a wide range of interventions with more of an empirical basis, particularly within the juvenile delinquency field • Youth rights and oversight – Important caution is that treatment efforts should not be harmful

17. Outline of SBP Treatment • Sexually abusive behaviors range from non-contact offenses to penetrative acts • Offense characteristics include factors such as the age and sex of the victim, the relationship between victim and offender, and the degree of coercion and violence used • Treatment typically provided to youth with adjudicated or documented sexual offenses

18. Outline of SBP Treatment • Identifying and managing feelings • Feeling charts • Name what you are feeling right now • Controlling emotions – techniques, skills and mechanisms • Role-play • Dialectic Behavior Therapy (DBT) skills • Normative sexual education and behavior • Sexual timeline • “What is normal” and healthy sexuality • Sexual education 101

19. Outline of SBP Treatment • Define, understand and identify thinking errors • Use of thinking errors in everyday life • Use of thinking errors in sexual offenses • Identify thinking errors in others and self • Develop empathy • Step one – Identifying feelings • Identifying feelings in others • Victim stories in the form of “victim cams” • Identification of thinking errors

20. Outline of SBP Treatment • Managing impulses • Social skills training • SUDS – Seemingly important decision • Thinking error avoidance • Learning about own triggers • Coping skills and mechanisms • Understand sexual offenses, patterns and behavior • “Victim cams” • Sexual timeline • Thinking error examples • Sexual offense assignments

21. Outline of SBP Treatment • Understand cycle and dynamics of sexual offending • Identifying triggers and stressors • Cycle and build-up • People, situations and activities to focus on and those to avoid • Relapse prevention skills • Acting on feelings or “internal” state • Use of SUDS to stay safe • Personal rules for safety • Demonstrated use of protective skills and mechanisms • Healthy sexuality and sexual relationships

22. Outline of SBP Treatment • Individual therapist • “Customized” treatment vs. group therapy which does not always have time to focus on individual issues • Preparation of major assignments which are passed off in group therapy • Family therapy, including reunification and clarification • Most of the “heavy lifting” as it relates to treatment occurs in group • Demonstration of skills and “insight” • We have two groups weekly which are two hours long • Individual therapy at least one hour per week

23. TFM and Assessment • Current standards emphasize the importance of documentation and specific descriptions of the offense • ". . .sex offenders tend to lie about their offenses and are unreliable and deceptive in their verbal reports…" (Dougher, 1995) • Police reports

24. TFM and Assessment • Avoid developing assessments based on just verbal reports from parents and offending youth • Gather multiple sources of information • Parents or guardians of juveniles should be involved in the assessment and in the treatment process (Morenz and Becker, 1995) • Comprehensive assessments should include clinical interviews with the juveniles and family members • Evaluators should review victim statements, juvenile court records, mental health reports, and school records as part of their assessment (Becker and Hunter, 1997)

25. TFM and Assessment • Psychological tests add a "critical dimension" to comprehensive evaluations of juveniles who have sexually offended (Kraemer, Spielman, and Salisbury, 1995) • “Sexual Behavior Risk Assessment” a 16 hour standardized assessment developed by NOJOS

26. TFM and Assessment • Thorough assessment is critical because: • Clinicians are correct in judging recidivism 50% of the time – same as chance • Reduces time in treatment • Polygraph motivates youth to be more honest about sexual history and offenses

27. Assessment Tools • The Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR) • Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II) • Polygraph Testing • Abel Assessment for Interest in Paraphilias • Others

28. The Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR) • Empirically guided checklist designed to assist clinicians to estimate the short-term risk of a sexual re-offense for youth aged 12–18 years of age • Provides objective coding instructions for 25 risk factors (16 dynamic and 9 static) • Preliminary psychometric data (i.e., inter-rater agreement, item–total correlation, internal consistency) were found to be supportive of the reliability and item composition of the tool • Ratings significantly discriminated adolescents based on whether or not they had previously been sanctioned for a prior sexual offense

29. Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II) • Checklist to aid in the systematic review of risk factors that have been identified in the professional literature as being associated with sexual and criminal offending • Designed to be used with boys in the age range of 12 to 18 who have been adjudicated for sexual offenses • Can be used with non-adjudicated youths with a history of sexually coercive behavior

30. Polygraph Testing • Use of polygraph tests in treatment programs for juveniles who have been sexually abusive is increasing (National Adolescent Perpetrator Network [NAPN], 1993) • Facilitates more complete disclosures of sexually abusive behaviors and to monitor compliance with treatment

31. Polygraph Testing • Research regarding the reliability and validity of the polygraph for assessing juveniles who have committed sex offenses is very limited (Hunter and Lexier, 1998 • We use polygraphs at the beginning of treatment to evaluate the youth sexual behavior timeline, number of victims and severity of the offenses

32. Other Assessment Tools • Phallometric assessment is a direct measurement of an individual's sexual arousal to deviant behavior • Potential ethical concerns using phallometric assessment with juveniles (Bourke and Donohue, 1996; Cellini, 1995) • Abel Assessment for Interest in Paraphilias (Abel Screening, Inc., 1996) is significantly less invasive than phallometric assessment, and research conducted by the test developers has shown good results • An independent study of the Abel Assessment's reliability and validity raised questions about the use of this assessment approach with juveniles (Smith and Fischer, 1999)

33. Clinical Treatment • Therapists are “experts” who provide critical information • Must be consulted as a valuable part of the treatment team • Expert but not the decision-maker

34. Clinical Treatment • Consultants decide how to mitigate risk • Clear understanding of who makes the final decision • Either program director, consultant or therapist • Recommend that it be someone who is an expert in TFM

35. Clinical Treatment • Therapists make decisions concerning safety • Do not let therapists take control of treatment by citing safety issues • Therapist wants to take away cell phone because the youth may make calls to sex lines is not a safety issue • Youth is “in cycle” and must be limited in movement is not safety

36. Written Assignments • Clinicians assign: • Timeline of sexual history • Definitions of sexual terms • Victim clarification assignments • Thinking errors • Assault characteristics • Seemingly Unimportant Decision (SUD) assignments • Journals with arousal logs • Treatment providers follow-up, provide feedback and reinforces

37. Family Teachers and Treatment Parents • Training on working with sex offenders • Dynamics • Risk factors • How clinical treatment is completed • Reunification/clarification • The importance of skills for treatment

38. Family Teachers and Treatment Parents • How to support clinical work • Follow-up on assignments • Normalizing sexual experiences • Reports aberrant behavior and deviant thinking

39. Family Teachers and Treatment Parents • No joking about sex offender treatment or assignments • Nervous and embarrassed • Locker room mentality • Use appropriate language • Body parts • Sexual behavior • Pornography • Family meeting on healthy sexuality and education just as with sexual victims

40. Program Mechanisms • Risk Management protocols • Clinicians need to external/objective measures to assess risk • Yearly or bi-yearly review of “incidents” and an assessment of how to manage future risk

41. Program Mechanisms • Important to teach youth to identify skills and coping mechanisms they can use to exit cycle and manage impulses • Allow youth to choose skills to help them in sex offender treatment

42. “Girl Rule” • Standards for acceptable conduct with individuals which have potential for a sexual relationship • Primarily for the family teachers and treatment parents • Emphasize normative behavior, integrating safety and treatment

43. Working with Schools • Provide customized assessments from clinician • Train family teachers and treatment parents how to interact with school officials • Never call school first with an issue or problem • Pre-teach family teachers about how to communicate information • Realize that school officials see your youth as a risk

44. Lesson Learned • Address thinking errors • Resistance of agencies to label children “offenders” and instead call them reactive may be appropriate for 12 years and younger and if they have been victims • Cannot have these children with other children

45. Lesson Learned • Moved all our youth out of foster care and group homes • We had offenders in treatment foster care, just didn’t say, then made them part of our continuum in NOJOS • Mixed offenders with non-offenders (still see agencies who do this)

46. Lessons Learned • Considerations • Polygraph your youth and their timeline • Know the pornography that arouse your youth • Define pornography, sexual content, mature information, etc. • Clarification and reunification before home visits

47. Lessons Learned • Safety issues decided by therapist but don’t let them cite safety issues to override your program and take it away from skill building • Safety is important, yearly risk assessment as a team, barriers are critical • No children in home

48. Lessons Learned • Safety plans • Family teachers need to own treatment, therapist needs to own the sexual offending psychodynamic parts of treatment • Therapists are not trained in the model and want to develop their own program rather than learn TFM

49. Lessons Learned • Avoid “integrating” programs • Integration of school, home and therapy stalled treatment • Work together on issues and sharing behavioral information • Combining motivation systems between three programs will frustrate and distract youth • Need to be successful in each domain to progress • Don’t let your clinicians or treatment providers tell the school what to do

50. Lessons Learned • Normalize sexual behavior-don’t teach them to look away • Teach them skills to manage deviant fantasies • Need perspective on healthy sexuality