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

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

• Ronald J. Ricci, Ph.D. Cheryl A. Clayton, L.C.S.W.

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Agenda

• Current state of the field
• Emerging theories of sexual offending (What they
  offer. What they dont)
• The knitting of these theories into an approach
  to treatment
• The missing piece
• The specific treatment components of the expanded
  model

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Before We Start.a word about roles.

• The Containment Model
• Probation
• Treatment
• Polygraph

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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).

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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 Californias Sex
  Offender Treatment and Evaluation Project
  (SOTEP). Sexual Abuse A Journal of Research
  Treatment, 17, 79-107.

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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)

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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

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Observations

• Despite everyones 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 cant feel what I know I should feel
• I just cant do what I know I should do
• I hear what youre saying, and I know its right,
  but I just dont believe it

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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

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Program Philosophy

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

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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

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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

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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

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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

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Phallometry Results

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Qualitative Results

• Recognition of Contributors to Distorted Beliefs
• I think what he done to me made me think its
  okay to have sex with younger people as long as
  you dont 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. Id look at it, and it was
  all mixed up, twisted. Now my mind, its like
  theres meat here, and potatoes, and a vegetable
  over here. Its like that now.

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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

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• 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

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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)

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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

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Prochaska and DiClementes Stages of Change Model
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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

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Risk Need Responsivity What It Does

• Reduce maladaptive behaviors
• Eliminate distorted beliefs
• Remove problematic desires
• Modify offense-supportive emotions and attitudes

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Risk Need What It Doesnt

• 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

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Self-Regulation Model of the Relapse Process

• Ward, T., Hudson, S.M., Keenan, T. (1998)

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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)

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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 Wards (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.

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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)

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SRM Offense Related Goals

• Avoidant
• Approach

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SRM Regulation Styles

• Under-regulation
• Mis-regulation
• Effective regulation

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SRM The Four Pathways

• Avoidant Passive
• Avoidant Active
• Approach Automatic
• Approach Explicit

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Summary of Four Pathways
PATHWAY SELF-REGULATORY STYLE DESCRIPTION
Avoidant-Passive Under-regulation Desire to avoid offending but lacks coping skills to keep it from happening- escape from self-awareness
Avoidant-Active Mis-regulation Desire to avoid offending but uses ineffective or counterproductive strategies
Approach-Automatic Under-regulation Overlearned sexual scripts, impulsive, poorly planned behavior. (Auto-pilot)
Approach-Explicit Effective regulation Desire to sexually offend with effective strategies towards that end
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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

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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

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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

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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

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SRM What it Does

• Considers etiology that then guides treatment
  intervention
• Considers differences in offense styles that then
  guides treatment goals

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SRM What It Doesnt

• Provide a means of addressing vulnerability
  factors beyond self-awareness
• Consider the contextual variables of the therapy

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The Good Lives Model of Offender Rehabilitation

• Ward, T., Gannon, T. (2006)
• Ward, T. Stewart, C.A. (2003)

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GLM Says

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

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GLM believes.

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

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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

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GLM assumes

• Core values drive daily activities and lifestyle.
• Daily activities and lifestyle shape
  self-perception.

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GLM Recommends

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

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GLM says

• Human beings are contextually dependent
  organisms. Rehabilitation must consider the match
  between the offenders characteristics and the
  environment into which he lives/will live.

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In the GLM

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

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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

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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

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GLM What it Does

• Addresses treatment motivation
• Frames offending in non-threatening and
  accessible context
• Offers replacement behaviors

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GLM What It Doesnt

• 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

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The Missing Piece

• A Trauma Informed Lens Through Which To View The
  Problem

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This is not your fathers trauma
We came to recognize that other trauma related
issues often surface and are resolved in the
process of trauma treatment. The etiology of the
offending problem often involves issues other
than sexual abuse. Other issues interfering with
the ability to form intimate peer relationships
(e.g., loss, rejection, attachment ruptures,
physical and emotional abuse) came to light as
relevant in the trauma processing. These are what
we recognize as dynamic risk factors.
Understanding and resolving the origins increases
the chances of improved treatment engagement AND
sustained treatment effects.
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Trauma Informed LensAdaptive Information
Processing F. Shapiro

• The approach is to view clients through the lens
  of looking for etiological issues at the
  beginning and throughout the treatment process
  and recognize that dysfunctionally stored
  memories from childhood/adolescence set the stage
  for future behavior and can push problematic
  behavior in adulthood. We look for the implicit
  beliefs that stem from childhood events including
  beliefs about the world in general as well as
  views of self and others that contribute to
  dynamic risk factors. These issues can
  potentially be resolved as we assist clients in
  clarifying them. As a by-product, clients often
  come to recognize a connection to their sexual
  offending which furthers their motivation to
  address them throughout the treatment process.
• It has much to do with the way we view our
  clients problem.

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• Stages of Treatment

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Why Am I Sitting Here?

• Pre-contemplation stage of change
• Offense introduction
• Do NOT coach or you will create a Parrot
• Tag subtle distortions, minimizations, etc. aloud
  and predict clarity in future

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Pacing Leading

• Attacking a clients position, particularly
  prior to establishing a working therapeutic
  relationship, is likely to damage sense of self,
  impede trust-building, and entrench the clients
  negative position. Aggressive treatment
  approaches markedly decrease the chances that the
  sexual offender will attain treatment goals.
• (W.L. Marshal et al. 2002)

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Pacing Leading (cont)

• Having the offender "parrot" a list of risk
  avoidant techniques (that internally he believes
  has nothing to do with him) results in a client
  that looks and sounds safe, but that will likely
  choose not to be safe when out from under the
  watchful eye of containment.
• Attempts to reduce deviant arousal prematurely,
  while cognitive distortions remain (part of her
  really did like it he's doing fine, it didn't
  really affect him as they say), is destined for
  failure.

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Pacing Leading (contd)
The pacing of treatment is important. For
example, Ward, Yates Long (2006, p. 76) caution
that self efficacy should not be enhanced until
offense-avoidance skills are effectively
developed and have become part of the individuals
repertoire and regular functioning. This is
because an increase in efficacy expectations
without the development of concomitant skills can
place the individual at higher risk to
re-offend.
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What Is This Problem Called Sexual Offending?

• Pre-Contemplative or Contemplative Stage of
  Change
• Non-threatening education about the problem
• Personalize concepts as ready
• Do not create an us-them dynamic
• Importance of Pacing Leading

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Psycho-Education Topics Woven in to Process Group
(as needed)

• Health Communication
• Assertiveness Training
• Anger/Behavior Management
• Stress Management
• Cognitive Restructuring
• Healthy Sexuality
• Empathic Interaction
• Sexual Reconditioning
• Relapse Prevention

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How Does The Problem Relate to Me?

• Moving from Contemplation to Preparation and
  Action Stages of Change
• Message The group wants to collaborate with the
  client to help him figure out his problem

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Full Offense History Disclosure

• Polygraph
• Expectation from beginning is that full
  disclosure is important
• Preparation is done with group support
• Less than perfect offense introduction is
  tolerated, flagged aloud for future intervention
• Not everyone will be here at this point

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Life History-Sexual Development

• What clients are encouraged to look at here are
  dependent upon their identified offending pathway
• Allows for the establishing therapeutic rapport
• Allows for connection between clients
• Identification of vulnerability factors and
  trauma targets

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Life / Sexual Development History Avoidant
Passive Pathway
Avoidant-Passive offenders are encouraged to look
at life history with an eye towards understanding
key experiences and events that impact present
level of functioning. Naturally, the clients
life choices and current behaviors are selections
he makes based on his core beliefs, shaped
through the lens of his view of the world. These,
then, can be examined in relation to the human
goods he was seeking through his offense-related
behaviors. For example, early experiences may
have left him vulnerable to feelings of
abandonment, and ill-equipped to manage those
feelings when they arise. This may create a core
belief that he is unworthy of relationships
which, coupled with his innate need for intimacy,
may lead him to seek intimacy with someone who is
non-judgmental, less-threatening, and easier to
impress, such as a child.
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Life / Sexual Development History Avoidant
Active Pathway
Avoidant-Active offenders are encouraged to look
for life experiences that make them vulnerable
to offending. There is a relationship between
life events, dynamic risk factors, and the
clients search to achieve primary human goods.
The client is looking back, therefore, for life
events that shaped his core beliefs in such a way
that his efforts to obtain human goods took the
form of offense-related behaviors. They may also
discover origins of adherence to ineffective
strategies that result in goal failure (i.e.,
avoiding offense-related behaviors).
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Life / Sexual Development History Approach
Automatic Pathway
Approach-Automatic offenders are looking for life
experiences that fostered and entrenched
long-standing scripts from which they
automatically respond to situational cues. Some
cognitive scripts evident in these types of
offenders include a sense of entitlement
(including sexual entitlement), hostile
attitudes, stereotyped beliefs, suspiciousness,
and distorted beliefs about children/females,
child development, etc.
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Life / Sexual Development History Approach
Explicit Pathway
Approach-Explicit offenders are looking for
origins of well-entrenched offense-supportive
attitudes. He may also be able to discover
origins of entitlement, or desires for
retribution. As he identifies the meaning of
these early experiences to his offending, he also
comes to see that he was attempting to achieve
life goals/human goods, and is more open to
looking at other, pro-social ways he might be
able to achieve those goods/needs.
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Trauma Treatment

• Trauma Treatment is done at this point to target
  those memories identified as contributing to
  development of offending problem (attachment
  issues, intimacy deficits, physical, emotional,
  sexual abuse). Those issues consistent with the
  Self-Regulation Model etiological pathways.

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Final Form of Offense Introduction

• A complete and distortion-free offense
  introduction
• Respectful language
• Do not include legal consequences
• Collaboratively identify offense pathway and
  tailor treatment plan accordingly
• Non-deceptive full disclosure polygraph

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Sexual Offense Histories

• Include all novel pathways
• Refine pathway analysis
• Extract distortions, rationalizations, etc. (the
  grease that moves the wheel)
• Lays groundwork for offense pattern

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The Problem Tends to be Cyclical

• Clarify awareness of risk of future offending
• If I reengage in problematic behaviors identified
  in treatment my risk to sexually re-offend is
  increasing

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Sexual Reconditioning

• For those with documented deviant arousal only
• Do not attempt until all evidence of cognitive
  distortions eliminated

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What Is The Cyclical Nature of MY Problem?

• Vulnerability Factors
• Triggers, Stressors, Motivators
• Maladaptive Coping Skills
• Selections, Planning, Grooming, etc.
• Post-Offense Evaluation

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Trauma Treatment

• Trauma Treatment done here on those issues that
  clients and clinicians note client continues to
  trip over. These are typically the issues
  triggering the beginnings of offense pattern
  (feelings of abandonment, overwhelming need to
  please others, feeling used, etc.)

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How Can I Avoid Doing This Again?

• Predicted pattern of offending
• Contributing, Vulnerability, and Risk factors
• Personal Values, Human Goods, Primary Goods, Needs

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Contextual Systemic Approach

• Community support person(s) as treatment partner
• Human beings are interactive and live in context
• Plans must realistically match environment

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Relapse Prevention-Good Life

• Internal Triggers Responses
• External Triggers Responses
• Achievement of Human Goods
• Typically a recounting of the life they have been
  living as treatment has progressed

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Practice

• Practice
• Practice
• Practice

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Phase-Out

• If probation supervision remaining after
  treatment completion, client develops a plan to
  phase out of weekly treatment attendance.

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• What does a trauma informed approach to therapy
  add to the treatment process?

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Related Publications

• Ricci, R.J., Clayton, C.A. (in press May 2009).
  EMDR with sex offenders in treatment. In R.
  Shapiro (Ed.) EMDR Solutions II for depression,
  eating, performance, and more. Norton.
• Ricci, R. J., Clayton, C.A. (2008). Trauma
  resolution treatment as an adjunct to standard
  treatment for child molesters. Journal of EMDR
  Practice and Research, 2(1) 42-51.
• Ricci, R. J., Clayton, C.A., Shapiro, F.
  (2006). Some effects of EMDR on previously abused
  child molesters Theoretical reviews and
  preliminary findings. The Journal of Forensic
  Psychiatry Psychology, 17(4) 538-562.
• Ricci, R.J. (2006) Trauma resolution using EMDR
  with an incestuous sex offender An instrumental
  case study. Clinical Case Studies, 5(3), 248-265.