Mary Owen, LCSW-R Chief of Service, SLPC – SOTP Jayme Smith, Psy.D.

1. 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

2. 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

3. Defining the Population Sexual abusers Moderate to high sexual recidivism risk Cognitive impairment Serious and persistent mental illness

4. 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

5. COMMON MISCONCEPTIONS ABOUT SPMI AND CI SEX OFFENDERS AND TREATMENT

6. 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)

7. 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

8. SEX OFFENDER TREATMENT CLIMATE

9. Setting the Treatment Climate Traditional approaches to sex offender treatment are NOT effective! Aggressive Confrontational Hostility “Hot Seat”

10. 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

11. Setting the Treatment Climate Therapist characteristics influence treatment gains (Marshall, et al., 2002) Empathy Warmth Directive Rewarding Firm but supportive challenging

12. 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)

13. TREATMENT FOUNDATION

14. 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

15. FRAMING SO TREATMENT

16. 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

17. 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

18. Good Practice Target treatment to the whole person Focus on dynamic risk factors Emphasize dynamic growth Manage symptoms Train to learning styles

19. ASSESSMENTS TO INFORM TREATMENT

20. 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

21. 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

22. 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

23. 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

24. 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

25. TREATING DYNAMIC RISK IN OFFENDERS WITH SPMI

26. 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.”

27. 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

28. ADDITIONAL CONSIDERATIONS Self-regulation Social Skills Medication Adherence

29. Practical Applications • Disclosure • Autobiography • Relapse Prevention Plan

30. 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

31. Schizophrenia and Cognitive Dysfunction Most common difficulties: Attention Memory Executive functioning Note: those with negative symptoms often have more cognitive difficulty

32. 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)

33. 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

34. BEST TREATMENT STRATEGIES

35. 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)

36. 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)

37. Offense Supportive Attitudes Group process (Autobiography, Self Disclosure) Cognitive restructuring Confront & supply data Self report to evaluate

38. 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

39. 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

40. Problem Solving Develop partnership (supportive presence; collaborative problem solving) ID skill for development (model, role play, practice, performance feedback, real life practice)

41. 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

42. 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

43. Self-regulation • Impulse Control Training • Motivation for Treatment • Medication • DBT • Pointing for Boundaries

44. COGNITIVE IMPAIRMENT

45. 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

46. 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)

47. Practical Applications • Disclosure • *Denial* • Autobiography • Relapse Prevention Plan

48. 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

49. 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)

50. 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