Remaking Relapse Prevention

1. Remaking Relapse Prevention

2. “Determinants of Relapse” (Marlatt & Gordon, 1980) New type of cognitive-behavioral intervention Relapse prevention

3. Relapse prevention Maintaining change in addicts Ceased Through other interventions

4. Relapse Rates for Addictions First 12 months after cessation 80% First 3 months 66% (Hunt et al., 1971)

5. Negative emotional states Interpersonal conflict Social pressure 71% of all relapses (drinkers, smokers, heroin addicts, compulsive gamblers, and over eaters) (Cummings et al, 1980)

6. Deviant Cycle Life Event Negative Affect Remorse, Guilt, or Fear Seemingly Unimportant Decisions (SUDS) Offense Thinking Errors Grooming or Force High Risk Situations Planning Passive/Active Target Selection

7. Developed for Offenders motivated to change Already ceased offending Offended through “seemingly unimportant decisions”

8. Not Developed For Psychopaths Child molesters who want to continue

9. “An important precondition for applying RP interventions is that the offender be motivated to stop offending.” (George & Marlatt, 1980, p. 16)

10. In the Beginning “the confidence and optimism we feel . . . are quite strong . . . “our confidence . . . is without empirical support” (Gordon & Marlatt, p. 28)

11. Why Was RP Adopted So Readily? No other game in town Northwest Treatment Associates Seattle, WA Gene Able & associates NY/Atlanta

12. What is RP today? “Relapse Prevention” Has little meaning “In the past 15 years, those words have served as an umbrella under which a huge variety of clinical interventions that had little or nothing to do with the original notions of RP could be found.” (Laws, 2000, 0. 16)

13. Nationwide Survey RP Includes Primary RP • Community 18% 97.9% • Residential 25% 93.4% (McGrath et al., 2002)

14. Cognitive Behavioral Treatment • Empathy • Assertiveness • Social skills • Healthy sexuality • Intimacy training • Cognitive distortions • Cognitive skills • Relapse Prevention

15. “Relapse prevention “performed a deep alchemy through which clinicians could look at rapidly declining survival curves and see mission, not despair.” (Hanson, 2000, p. 36)

16. Instilling Knowledge of RP Satisfactory offense chains Initial testing 39% 3 repetitions 100% (Marques et al., 1989)

17. Test of Basic RP Concepts Initial testing 34% 3rd testing 100% (Marques et al., 1989)

18. Sex Offender Treatment and Evaluation Project(Marques, 1999)

19. Was SOTEP a Test of RP? • Sex education • Human sexuality • Relaxation training • Stress & anger management • Social skills • Substance abuse • Deviant arousal • RP

20. SOTEP Chronic offenders Mastered RP model Lower recidivism rates All offenders No relationship Mastering RP & recidivism

21. RP & Low Risk Offenders SOTEP Mastering RP No lowered recidivism No cycle?

22. Why Did SOTEP Fail? Failure to motivate offenders Lack of challenge of offenders Too little focus on affective factors Lack of practice in coping skills Lack of a strong conditional release component

23. Instilling Knowledge of RP Community based tx in England 27%

24. RP Too Complicated • Abstinence violation effect • Success expectancy • Erroneous attributions • Apparently irrelevant decisions • Negative emotional state • Problem of immediate gratification • Adaptive coping response • Increased probability of relapse

25. RP Can Be Taught • Awareness of high-risk thoughts • Willingness to admit planning • Recognition of high risk factors • Knowledge of motivation for offending • Ability to think of coping strategies • Ability to tell others when at risk Exposure to RP greater skills (Mann, 1996)

26. Summary RP dominant tx strategy for 15 years Rarely as a solo program Hard to teach When mastered, ability to think of coping strategies and tell others risk level

27. Losel & Schmucker2005

28. Negative Results Kenworthy, Adams, Brooks-Gordon & Fenton, 2004 Rice and Harris, 2003

29. Does Tx Work Long Term? 12 Year Follow-Up Treated Untreated (403) (321) Sexual 21.1% 21.8 Violent 42.9% 44.5% General 56.6% 60.4% (Hanson et al., 2004)

30. Updated Relapse Prevention

31. Deviant Cycle Life Event Negative Affect Remorse, Guilt, or Fear Seemingly Unimportant Decisions (SUDS) Offense Thinking Errors Grooming or Force High Risk Situations Planning Passive/Active Target Selection

32. Self Regulation Model of Relapse Prevention Life Event Sometimes Desire for Offensive Sex (Ward & Hudson, 1998)

33. Self Regulation Model of Relapse Prevention Desire for Offensive Sex Avoidance Goals Approach Goals (Ward & Hudson, 1998)

34. Self Regulation Model of Relapse Prevention Avoidant Approach Passive Active Automatic Explicit (Ward & Hudson, 1998)

35. Type of Offense Pathway: Roger • Unemployed • Bar from 12 to 3 pm • Left drunk • Boarded a train as “knew girls would be there” • Goals: get one to perform oral sex

36. Type of Offense Pathway: Roger Sat behind two 13-year-olds Touched their hair and masturbated Tapped one on shoulder They got up and left Got off train, saw a 13-year-old Began masturbating

37. Type of Offense Pathway: Roger • Walked up to her with penis out of pants • Wanted her to perform oral sex • She called out and other girls joined her • Bus arrived and they left • They reported to bus driver

38. Type of Offense Pathway: Roger “I just do things for no reason.” “I wish I could put into words how I feel, and understand what it is all about.”

39. Type of Offense Pathway: Roger • Knew by heart the routes home of children from local schools and holidays and breaks • It was “familiar territory” so never had to plan • Says “thousands” of victims • Convicted 13 times

40. Type of Offense Pathway: Roger • Says he felt children enjoyed the experience • “I don’t hurt anyone and people quite like what I do. I never carry out my fantasies about rape and hurting people in real life.”

41. Roger: What Kind of Offender? Approach Automatic

42. What Kind of Treatment?

43. Type of Offense Pathway: Dave • 40 year-old • Confident and outgoing • Worked abroad in a program to help teen prostitutes • Talked to pimps • They made a “powerful case” • Felt his values had “become contaminated”

44. Type of Offense Pathway: Dave “Some of the younger girls I was trying to help said that things about the life were good. Intellectually I knew that that was about comparisons with the life they had before, extreme poverty and so on, but at another level I got interested – although I never did anything wrong to them.”

45. What Type of Offender: Dave • In past had baby-sat for 11-year-old • Went in bedroom aroused and watched child sleep • Told wife • Agreed never to babysit again

46. Type of Offense Pathway: Dave • I talked to my wife about the babysitting experience before we had the children. That was good, but then I sort of laid the responsibility for stopping it happening again on her. I did that again after our daughter told her what I’d been doing.”

47. Type of Offense Pathway: Dave • Family living in an open-plan home in hot climate • Kids often undressed • Felt 10-year-old daughter was seductive • Knew his arousal was wrong • Tried to avoid situations where he might abuse her

48. Type of Offense Pathway: Dave • Refused to share a tent with her on camping trip • Other times he fondled her genitals • Once persuaded her to straddle him • Told himself knew what was happening and agreed

49. Type of Offense Pathway: Dave • When wife gone, got into daughter’s bed to have intercourse • Realized what he was doing and stopped • Shaken that he almost raped her

50. Type of Offense Pathway: Dave • “I thought that carrying on with my work would help me get my head straight – instead it was just making it worse.”