Trauma Informed Sex Offense Specific Treatment An approach to CBT-RP Treatment

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

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

3. Before We Start….a word about roles. • The Containment Model • Probation • Treatment • Polygraph

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

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

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

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

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

9. A Further Observation Clients with childhood sexual abuse (CSA) often times demonstrate lack of trust, intimacy deficits, emotional constriction, and implicit beliefs about themselves and/or their victims that impede treatment progress and contribute to re-offense risk

10. Program Philosophy • Community Safety • Individualized • Consider client readiness • Collaborative and Structured • Insight oriented • Based in relationship (treatment, group, inner and outer circle) • Systemic

11. Procedure • Ten sexual offenders in a CBT-RP treatment program with reported histories of child sexual abuse were selected to undergo EMDR trauma treatment as a adjunct to their standard CBT-RP program • Pre-treatment TSI, SOTRS, and PPG measures were obtained • An average of six EMDR sessions using standardized protocols (Shapiro, 2001) were conducted with the 10 EMDR-added treatment group clients. EMDR treatment was considered complete when participants reported an SUD as low as they expected their disturbance could become • Post-treatment TSI, SOTRS, and PPG data were obtained for the EMDR-added treatment group. Follow up data were obtained from 8 of the 10 participants • PPG data were obtained from the remaining child molesters in the same treatment program to serve as a control

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

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

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

15. Phallometry Results

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

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

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

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

20. Treatment Theories The overarching program model and the specific treatment components consider: Trans-theoretical Change Model; Risk, Needs, Responsivity Model, Self-Regulation Model, Good Lives Model, and Foundational Issues/Trauma Model

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

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

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

24. Risk – Need: What It Doesn’t • Consider contextual factors • Consider the relationship between risk factors and human needs or goods • Address treatment readiness • Focus on therapeutic relationship, therapist factors, offender attitudes

25. Self-Regulation Model of the Relapse Process Ward, T., Hudson, S.M., & Keenan, T. (1998)

26. SRM in brief… • Contains a number of pathways, representing different combinations of offense-related goals and distinct regulation styles in relation to sexually offense contact. (Ward et al., 2004)

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

28. Vulnerability FactorsWard & Siegert 2002 • Intimacy & Social Skills Deficits • Distorted Sexual Scripts • Emotional Dysregulation • Offense Supportive Beliefs • Any or all of the above PLUS Deviant Sexual Scripts (oftentimes from childhood sexual victimization)

29. SRM – Offense Related Goals • Avoidant • Approach

30. SRM – Regulation Styles • Under-regulation • Mis-regulation • Effective regulation

31. SRM – The Four Pathways • Avoidant – Passive • Avoidant – Active • Approach – Automatic • Approach – Explicit

32. Summary of Four Pathways

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

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

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

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

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

38. SRM: What It Doesn’t… • Provide a means of addressing vulnerability factors beyond self-awareness • Consider the contextual variables of the therapy

39. The Good Lives Model of Offender Rehabilitation Ward, T., & Gannon, T. (2006) Ward, T. & Stewart, C.A. (2003)

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

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

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

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

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

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

46. In the GLM • CRIMINOGENIC NEEDS are internal or external obstacles that frustrate and block the acquisition of primary human goods.

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

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

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

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