Coalinga State Hospital and Evidence-Based Treatment for Sex Offenders

1. Coalinga State Hospital and Evidence-Based Treatment for Sex Offenders Bill Holcomb, PhD & Jerry Kasdorf, PhD May 13, 2010 California Coalition on Sex Offending San Diego, CA

2. Importance of Asking the Right Questions Before We Act!

3. The Right Questions • Does sex offender treatment work? • How do we evaluate our processes for treatment? • What therapist variables are important for change? • What are the appropriate targets of treatment? • How does the evidence match what we are doing and our other accreditation and certification guidelines?

4. Does Treatment Work? Meta-analyses of Sex Offender Treatment Outcomes (Adults) Study Effect size Hall (1995) .24 Gallagher et al. (1999) Overall .43 CBT/RP .47 Hanson et al. (2000) Overall .11 CBT/RP .28 Dowden et al. (2003) RP only .13 From William Marshall (2006) - Appraising Treatment Outcome with Sex Offenders

5. Important Lessons from SOTEP! Group n yrs at risk Sex reoff.(%) Violent (%) RP (all) 259 8.3 22.0* 16.2* withdraw 55 7.9 20 12.7 RP<1 yr 14 8.4 35.7 28.6 RP>1 yr 190 8.4 21.6 16.3 Volunteer Con. 225 8.4 20.0 11.6 NonVol. Con. 220 8.3 19.1 15.0 *note: not duplicate counts

6. A Program That Works? Canadian Federal Prison StudyMarshall, et al. (2006) - Treating Sexual Offenders: An Integrated Approach • Operated for 15 years • 614 total offenders with 534 followed for 5.42 years in the community • 352 child molesters, 182 rapists • Only 17 rearrested - 14 child molesters and 3 rapists • 3.2% recidivism rate for a sexual crime • 13.6% recidivated on a nonsexual crime • Based on norm base rates, the expect recidivism rates are 16.8% for sexual offending and 40% for non-sexual offending • Of the 17 who re-offended, none were sadists and only two scored > 20 on the PCL-R and none above 20

7. Risk/Need/Responsivity Model of RehabilitationBonta & Andrews (2003) Four principles that should guide treatment: 1. Risk:: offenders at higher risk of re-offending will benefit most from higher levels of intervention: • Need: factors associated with reductions in recidivism (i.e. criminogenic needs) should be targeted in treatment • Responsively: correctional programs should be matched to individual’s personal and interpersonal circumstances • Professional discretion: clinical judgment should override the first three principles

8. RNR for Sex Offender TreatmentRichard Laws (2008) Criminogenic needs: Deviant sexual interests, antisocial orientation, attitudes tolerant of sexual assault, intimacy deficits Noncriminogenic needs: Victim empathy, denial/minimization, lack of motivation, anxiety, depression, low-self-esteem, sexual abuse as a child

9. Therapist Characteristics and Positive Outcomes • The quality of the therapeutic alliance accounts for as much as 25% of the variance in treatment effectiveness in general psychotherapy research • 40% of group effectiveness due to cohesiveness and expressiveness of group • Key interpersonal therapist skills: Empathy Emotional responsivity Self-disclosure Genuiness Warmth Open-ended questions Respect Directiveness Supportiveness Flexibility Confidence Rewarding behavior Ackerman & Hilsenroth (2003) Clinical Psychology Review

10. Accentuating the Positive - A Must! • Confrontational approach ignores research showing that clients are ambivalent about change • Diclementi (1991) indicated that a confrontational approach is particularly damaging to clients who are at the “Pre-contemplation” stage of change • Many sex offenders are referred for treatment when they are at a preliminary stage of change - characterized by client resistance and minimization • Patterson & Forgatch (1985) - increased non-compliance in clients significantly related to degree of confrontation in therapy • Outcome research with sex offenders - gains of clients exposed to confrontational therapy are either superficial or do not generalize outside of treatment (Fernandez, 2006)

11. The Right Goals: Approach vrs. Avoidance Goals • Research shows that avoidance goals are rarely maintained versus approach goals • People who have predominantly avoidance goals are less psychologically healthy, less happy, and less successful • Alcohol abusers who work toward avoidance goals are more likely to relapse than those with approach goals • With sex offenders - those with positive approach goals are more engaged in treatment, complete more homework assignments, are more willing to disclose problems, and are judged to be more motivated to live an offense free life • Recognize a need to revise Relapse Prevention

12. Good Lives Model of Sex Offender Treatment • Absence of a “good life” important in understanding the etiology and treatment of sex offending • “Primary Goods” • Life-healthy/optimal functioning, sexual satisfaction • Knowledge • Excellence in work and play - mastery • Excellence in agency - autonomy and self-directedness • Inner peace - freedom from turmoil and stress • Relatedness - intimate, romantic, kinship, community • Spirituality - meaning and purpose in life • Happiness • Creativity Ward, T., & Marshall, W. (2004). Good lives, aetiology and the rehabilitation of sex offenders: A bridging theory. Journal of Sexual Aggression

13. Motivational Interviewing Arkowitz, et al. (2008) Motivational Interviewing. Gilford Press • MI works from the assumption that many clients who seek therapy are ambivalent about change and that motivation may ebb and flow during the course of therapy • A central goal of MI is to increase intrinsic motivation to change – which arises from personal goals and values rather than from such external sources as others’ attempts to persuade, cajole, or coerce the person to change. In fact, external pressure to change can create a paradoxical decrease in the desire to change • Works at intake and throughout therapy

14. Targets of Treatment for Sex Offenders(Marshall et al., 2006) Offense-specific targets: • Self-esteem • Acceptance of responsibility • Victim (Broadening of…) empathy • Social/coping skills • Pathways to offending • Sexual interests • Self-management plans

15. Treatment Target #1 - Self-Esteem • Self-Esteem – belief in their capacity to change - enhances participation and motivation – Miller (1983) found that enhancing self-esteem in problem drinkers a necessaryprerequisite for behavior change. • Appropriate therapist behaviors and creating a productive group climate have been shown to be related to enhanced the self-esteem of sex offenders and nonoffenders (Beech and Fordham, 1997).

16. Target #2 - Acceptance of responsibility • Barbaree (1991) - 54% of rapists and 66% of child molesters are described as categorically denying committing the offense and 98% of all offenders either denying or minimizing their offense in some way. • In treatment minimizations, denials, and rationalizations are used to challenge the client’s cognitive distortions (Mann & Shingler, 2005) • Disclosure is used to focus initially on acceptance of responsibility

17. Acceptance of responsibility (2) • Hanson and Bussiere (1998) examined the relationship between denial and later re-offending. No relationship was found between any aspect of denial and later re-offending and therefore exhaustive recounting of all offenses is not thought to be productive and may jeopardize the relationship with the therapist. • Marshall, et al (2006) suggests that only two offenses that are typical of others committed by the offender be used to encourage disclosure.

18. Treatment Target # 3 - Victim Empathy • Help the client identify emotions in themselves and others • Each group member describes an emotionally upsetting experience as emotionally as possible - each group member then identifies the emotion expressed by the target person - each group member must identify a different emotion and also describe the emotion they themselves felt when the emotional story was described • Primary empathy deficit is toward the person they are victimizing to allow them to escape shame - an outgrowth of their cognitive distortions

19. Treatment Target # 4 - Social Skills • All clients participate in all sessions - practice improving skill deficits - lack of assertiveness, conversational skills, anxiety, anger, etc. • Clients identify their prototypical attachment style • Provide details of interactions, problems and positive features of past relationships • Discussion of human sexuality - i.e. equality, spontaneity, and affection - sexual offending by its nature is not equal • Discussion of origins of attachment styles, effective communication, jealousy, compatibility, and living without a partner • Problem of dysfunctional schemas that give rise to maladaptive attachment styles

20. The Skill of Coping with Stress • Serran and Marshall (2005) have established a connection between coping and mood that is bi-directional - inadequate coping leads to unstable mood and unstable mood leads to inadequate coping. • Research has also shown a that different types of sex offenders (i.e. child-molesters) have a tendency to use avoidance-focused coping and to use sex as a coping strategy (Cortoni and Marshall, 2001).

21. Treatment Target #5 - Pathways to Offending • Same as “offense chains” • Focus on background factors - creates temporary vulnerability or offense prone disposition - to seek out victims and avoid inhibitors • Background factors emerge from disclosure and autobiography • These often trigger deviant sexual fantasies • First step is to help client identify background factors.

22. Treatment target # 6 - Deviant Sexual Preferences • Deviant sexual interests or fantasies and consequent arousal have been linked with increased likelihood of sex offending (Quinsey, Harris, Rice, & Cormier, 1998), and therefore has been typically identified as an important target of treatment. • The assessment of deviant sexual interests and fantasies poses significant problems. Typically, four different strategies have been used: • Some research shows that deviant sexual interests decreases with targeted increase in self-esteem.

23. Treatment Target # 7 - Self-Management Plans • Plans can be constructed with clients that focus building more prosocial lives that will enable them to achieve their life goals. • It is crucial for therapist to help the client gain a sense of hope (Fernandez, 2006). Frank (1989) has argued that hope is the primary factor leading to positive therapeutic gain. The therapist should strive to use every opportunity in therapy to practice skills that enhance self-efficacy. • In regard particularly to sex offenders, Beech & Fordham (1997) found that one of the most important crucial elements in leading to positive change in group therapy was instilling hope in the clients.

24. Reasons for Change Efforts at Coalinga State Hospital • Even though many effective and innovative treatment efforts are in place, the overall program manuals and guidelines follow a more traditional relapse prevention model • Special considerations that must be addressed because over half of all offenders choose not to participate in treatment • The SVP laws and system are seen by individuals as minimizing external incentives for change efforts • The wellness and recovery model that currently guides institutional treatment in many settings parallel most recent sex offender literature, but these concepts need to be integrated into clinical programming