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Treating Dynamic Needs Sex Offenders with Cognitive Impairments & Serious/Persistent Mental Illness. Mary Owen, LCSW-R Chief of Service, SLPC – SOTP Jayme Smith, Psy.D. Licensed Psychologist, SLPC -SOTP. Learning Objectives.
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Treating Dynamic NeedsSex Offenders with Cognitive Impairments & Serious/Persistent Mental Illness Mary Owen, LCSW-R Chief of Service, SLPC – SOTP Jayme Smith, Psy.D. Licensed Psychologist, SLPC -SOTP
Learning Objectives Examine best practice strategies for training individuals with Cognitive Impairment (CI) & Severe & Persistent Mental Illness (SPMI) in order to understand implications for staffing & treatment delivery Integrate knowledge of Dynamic Factors into treatment practices for the CI & SPMI populations
Defining the Population Sexual abusers Moderate to high sexual recidivism risk Cognitive impairment Serious and persistent mental illness
Bridgeview Diagnoses Sexual Disorders 100% Pedophilia 64% Paraphilia (Rape, Sadism…) 36% Borderline Intellect 35% Psychotic Disorders 25% Personality Disorders: Antisocial 45% NOTE: Most common age range: 41-60
COMMON MISCONCEPTIONS ABOUT SPMI AND CI SEX OFFENDERS AND TREATMENT
Facts About SPMI and CI Sex Offenders Sex offenders w/ SPMI constitute about 8% of all men charged in a sex offence SPMI sex offenders are more similar than different from most offenders (Sahota & Chesterman, 1998) Not all SPMI offenders are driven to offend by the illness (Smith, 2000) Individuals with lower IQ’s are less prone to violence in offending (Murray et.al., 1992)
Factors That May Not Be Related To Sexual Recidivism Victim empathy Denial/minimization of sexual offence Lack of motivation for treatment Internalizing psychological problems Anxiety, depression, low self-esteem Sexually abused as a child Low conventional ambition Insufficient fear of official punishment
Setting the Treatment Climate Traditional approaches to sex offender treatment are NOT effective! Aggressive Confrontational Hostility “Hot Seat”
Setting the Treatment Climate General best practice applies Past separation of SO treatment and traditional therapy techniques and beliefs Therapeutic relationship as a curative factor (Norcoss, J., 2002; Horvath and Symonds, 1991;Frank & Gunderson,1990; Krupnick, et al. 1996) “Improvement in psychotherapy may best be accomplished by learning to improve one’s ability to relate to clients and tailoring that relationship to individual clients.” (Lambert and Barley, 2001) Especially important for SMPI
Setting the Treatment Climate Therapist characteristics influence treatment gains (Marshall, et al., 2002) Empathy Warmth Directive Rewarding Firm but supportive challenging
Setting the Treatment Climate • Hopelessness is a huge issue in civil confinement centers • Find a realistic goal that keeps hope alive • Increased hope is associated with reduced risk for re-offending (Prescott, 2009) • Build best context where clients can change (Mann, 2009)
COACH vs. KEEPER Focus on individual, not illness People change behavior for things THEY want Change occurs in stages & is tied to trust Positive outcomes can be crafted w/o changing the person Work from a place of respect
General Goals of SO Treatment Eliminate sexually assaultive behavior Reduce deviant sexual arousal Reduce criminality Correct distorted thinking Increase adaptive functioning Increase interpersonal skills Increase openness & trust Broaden interests beyond sexuality Educate about healthy sexuality
Treatment Specific to Sex Offenders - Model RNR Model (Andrews, Bonta & Hoge, 1990, 2006) Risk Level of risk considered with level of treatment Low risk vs. high risk Need Criminogenic Needs Responsivity Tailor treatment to offender Includes learning style, strengths, weakness, culture
Good Practice Target treatment to the whole person Focus on dynamic risk factors Emphasize dynamic growth Manage symptoms Train to learning styles
SO Treatment Specific for CI and SPMI - Assessments Assess for psychopathy Sexual deviance combined with psychopathy = increased risk of reoffense (Gretton et al. 2001; Harris et al., 2003) Assess IQ and the parameters of impairment Assess adaptive and social functioning Vineland Adaptive Behavior Scale Can help to determine more about motivations of sexual crime
SO Treatment Specific for CI and SPMI - Assessments Thorough clinical interview Assess severity psychiatric symptoms Clarify how psychosis is tied to sex offense Psychiatric Evaluation PPG
Initial Steps in SO Treatment for CI and SPMI Stabilize psychiatric patients Re-evaluate content of delusions to see if sexual beliefs have become more pro-social Review assessments to develop case conceptualization Basis of treatment planning
Case Conceptualization Gain deeper understanding of why the consumer committed the sexual crime Psychopathy = meeting needs without regard for others Align pro-social goals and self-interest Sexual deviance – sexual orientation towards children Evaluate for appropriate sexual arousal Focus on reconditioning / anti-androgens
Case Conceptualization Psychosis-based sexual beliefs No improvement of delusions while medicated External management Safety planning Poor Social Skills / Developmentally Delayed Focus on sexual education, social skills and safety training ‘Counterfeit deviance’ hypothesis More rare
Dr. Thornton says…. “The presentation argues that the psychological risk factors which we usually think of as dynamic generally function more like enduring traits so that they change only slowly and with difficulty. However, there is evidence that targeting psychological risk factors related to recidivism is more helpful than targeting other factors and that treatment participants can learn to manage these enduring traits more effectively so that those who manifest them less in environments that challenge the traits go on to show less recidivism than those who continue to manifest them.”
Dynamic Risk FactorsMann, Hanson & Thornton (2008) Sexual Preoccupation Deviant Sexual Interests Offense Supportive Attitudes Emotional Congruence with Children Poor Adult Attachment Lifestyle Impulsivity Resistance to Supervision Poor Problem Solving Grievance Thinking Hostility Negative Social Influences
ADDITIONAL CONSIDERATIONS Self-regulation Social Skills Medication Adherence
Practical Applications • Disclosure • Autobiography • Relapse Prevention Plan
Features of Mental Illness Lack of stable identity Disorganized thinking Vulnerability to stress / Changes in the environment Difficulty solving problems Poor self-care Social withdrawal Abandonment of family responsibilities Work incapacity
Schizophrenia and Cognitive Dysfunction Most common difficulties: Attention Memory Executive functioning Note: those with negative symptoms often have more cognitive difficulty
SPMI & SO Treatment • More open about sexuality • Increased sexual dysfunction (ED) • Increased faulty sexual knowledge (Hughes & Hall, ) SPMI is a disinhibitor – increases criminality, substance abuse, poor social skills, stranger victims (Sahota & Chesterman, 1998)
Factors Associated withSPMI Resiliency Good self esteem Impulse control Adequate social skills Ability to problem solve Good coping skills Ability to delay gratification Ability to manage stress Skill building Social Support
Sexual Preoccupation Promote Wellness Management (Self monitoring checklist) Inform on observation of arousal Thought stopping Arousal Reconditioning Consider medications to reduce arousal (SSRI, AAT, Clinician support in psychiatry consults)
Deviant Sexual Interests ID tie-in between delusions & deviance Journaling / charting (adaptive assist PRN – recorder Need vs. want / rational disputing Thought stopping Arousal reconditioning Consider medications to reduce arousal (SSRI, AAT, Clinician support in psychiatry consults)
Offense Supportive Attitudes Group process (Autobiography, Self Disclosure) Cognitive restructuring Confront & supply data Self report to evaluate
Emotional Congruence w/ Children • ID perception problems • Self perception • How others see you • Use of video to self assess • Could you see…. • Environmental structuring • Increase adult social / leisure skills
Poor Adult Attachments Develop support network (family, faith, providers…) Whole family education & advocacy Social skills training Appropriate relationships with staff members Increase ability to be intimate
Problem Solving Develop partnership (supportive presence; collaborative problem solving) ID skill for development (model, role play, practice, performance feedback, real life practice)
Grievance Thinking/Hostility • Cognitive restructuring • Find the emotion driving this • Immediate feedback • Rating Scale • 1 (not upset) – 10 (very upset) • Check perception against the group or therapist
Negative Social Influences • Observation in treatment setting/community • Help structure routines (ID options for activity, provide choices, schedule of daily activities) • Case Management • Day Treatment/Social Club • Formal contingencies • SIST • ACT Team • Kendra’s Law
Self-regulation • Impulse Control Training • Motivation for Treatment • Medication • DBT • Pointing for Boundaries
Static and Dynamic Factors(Lindsay, Elliot & Astell, 2004) Anti-social Attitude Poor Response to Treatment Offenses Involving Physical Violence History of Violence Staff Complacency Deterioration of Family Attitudes Unplanned Discharge Poor Maternal Relationship Low Self Esteem Lack of Assertiveness Attitudes Tolerant of Sexual Crimes Low Treatment Motivation Erratic Attendance and Unexplained Breaks from Routine
Static and Dynamic Factors – Differences The following factors MAY NOT be associated for recidivism in CI population: Employment History Criminal Lifestyle Criminal Companions Diverse Sexual Crimes Victim Choice (Lindsay et al., 2004)
Practical Applications • Disclosure • *Denial* • Autobiography • Relapse Prevention Plan
Standards of Care for CI Positive relationship Person-centered care Consistency of services (long term case manager – even when hospitalized) Team-based service Family participation to increase therapeutic reach
Cognitive Impairment (Horton & Frugoli, 2001) Modalities to Use: Psych-Ed (use pictures, art, role play, audio music) Narrative & Storytelling Family Work Skill Building/Practice Individual Work (to increase comprehension and reinforce/homework)
Anti-social Attitude • Token economy • Align pro-social actions with their goals • Emphasize rewards for pro-social behaviors • Consistent and immediate consequences for anti-social behaviors