Treating Youth With Sexual Offending Behavior:

1
Treating Youth With Sexual Offending Behavior

• Integrating Clinical Services in a
  Teaching-Family Model Program

Talon Greeff, MMHC Director of Residential
Care UTAH YOUTH VILLAGE [phone]
This training and additional resources can be
found at www.utahparenting.org
2
Introduction

• remember that although the goal when working
  with juveniles who have committed sex offenses is
  to help them stop their abusive behaviors, they
  are children and adolescents first.
• -Office of Juvenile Justice and Delinquency
  Prevention, 2001

3
Source Material

• U.S. Department of Justice, Juveniles Who Have
  Sexually Offended - A Review of the Professional
  Literature (2001)
• Network on Juvenile Offending Sexually (NOJOS)
• Association for the Treatments of Sexual Abusers
  (ATSA)
• National Adolescent Perpetrator Network (NAPN)

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Outline

• Introduction
• Hallmarks of Best Practice
• Teaching-Family Model Treatment Integration
• Treatment of Sexual Behavior Problems (SBP)
• Assessment and TFM
• TFM Program Treatment Mechanisms
• Working with schools
• Lessons learned in application of clinical
  treatment within a TFM program
• Suggestions for implementation in a TFM program

5
Utah Youth Village Continuum

• Continuum treatment arc
• Healthy sexuality groups
• Intensive outpatient group
• Foster care treatment
• Group home treatment in a community-based setting

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Utah Youth Village Continuum

• Continuum treatment arc
• Step-down into foster care and intensive
  out-patient
• Intensive family preservation transitional
  services

7
Utah Youth Village Continuum

• Clinicians initially developed our treatment
  using current research in treating youth with
  sexual offending behavior
• We have used outside clinicians for youth with
  these issues in treatment foster care
• The Teaching-Family Model works seamlessly and
  effectively in enhancing clinical treatment
  addressing sexual offending behavior

8
Hallmarks of Best Practice

• National Adolescent Perpetrator Network (1993)
  suggests that satisfactory treatment requires a
  minimum of 12 to 24 months
• Programs designed to focus exclusively on
  sex-offending behaviors are of limited value and
  have recommended a more holistic approach
  (Goocher, 1994)

9
Hallmarks of Best Practice

• Research is lacking on what works best other than
  it should be highly structured and include
  individual, family and group therapy

10
Hallmarks of Best Practice

• Lipsey and Wilson (1998) conducted a
  meta-analysis of 200 experimental or
  quasi-experimental studies to assess the
  effectiveness of treatment interventions used
  with juvenile offenders
• Among non-institutionalized juveniles, treatments
  that focused on interpersonal skills and used
  behavioral programs consistently yielded positive
  effects
• Other interventions that have been validated with
  chronic delinquents, such as multisystemic
  therapy and multidimensional treatment foster
  care, also are promising approaches for juveniles
  who have committed sex offenses (Borduin et al.,
  1990 Chamberlain and Reid, 1998 Swenson et al.,
  1998)

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Hallmarks of Best Practice

• Report of the ATSA Task Force on Children with
  Sexual Behavior Problems (SBP) found that
  incorporating some of these basic SBP elements
  into evidence-based treatments focused on the
  highest priority problems may be more feasible
  than adding or stacking separate therapies

12
Hallmarks of Best Practice

• Social skills and relationships
• Research repeatedly documents that juveniles with
  sexual behavior problems have significant
  deficits in social competence (Becker, 1990
  Knight and Prentky, 1993)
• Inadequate social skills, poor peer
  relationships, and social isolation are among the
  difficulties identified in these juveniles
  (Fehrenbach et al., 1986 Katz, 1990 Miner and
  Crimmins, 1995)

13
TFM Treatment Integration

• Provides a flexible, customized approach
• Emphasis on skills development to address
  maladaptive behaviors
• Effectively addresses mental health issues and
  Diagnostic of Statistical Manual (DSM) diagnoses
• Integration of clinical treatment for sexually
  maladaptive sexual behavior

14
TFM Treatment Integration

• Treatment providers should receive appropriate
  training before they begin their work and
  thereafter on a continuing basis.
• Working with juveniles who have sexual behavior
  problems is a challenging job
• NAPN (1993) observed, "Systems must be aware of
  potential emotional/psychological impacts on
  providers and take steps to protect against or
  counter negative effects" (p. 46)
• Consultation provides this support to both the
  TFM practitioners but also to the clinicians
• Clinicians receive one hour of consultation
  services weekly with a supervisor trained in the
  TFM

15
TFM Treatment Integration

• Teaching-Family Model programs meet these
  expectations
• Individualized - The literature clearly supports
  the importance of interventions that are tailored
  to the individual juvenile
• Strength-based - risk management most effective
  in programs which address needs underlying a
  juvenile's behavior emphasizing strengths and
  positive supports

16
TFM Treatment Integration

• Research-based and empirical - Although efficacy
  has not been established for many sex offender
  interventions considered standard and required,
  there are a wide range of interventions with more
  of an empirical basis, particularly within the
  juvenile delinquency field
• Youth rights and oversight Important caution is
  that treatment efforts should not be harmful

17
Outline of SBP Treatment

• Sexually abusive behaviors range from non-contact
  offenses to penetrative acts
• Offense characteristics include factors such as
  the age and sex of the victim, the relationship
  between victim and offender, and the degree of
  coercion and violence used
• Treatment typically provided to youth with
  adjudicated or documented sexual offenses

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Outline of SBP Treatment

• Identifying and managing feelings
• Feeling charts
• Name what you are feeling right now
• Controlling emotions techniques, skills and
  mechanisms
• Role-play
• Dialectic Behavior Therapy (DBT) skills
• Normative sexual education and behavior
• Sexual timeline
• What is normal and healthy sexuality
• Sexual education 101

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Outline of SBP Treatment

• Define, understand and identify thinking errors
• Use of thinking errors in everyday life
• Use of thinking errors in sexual offenses
• Identify thinking errors in others and self
• Develop empathy
• Step one Identifying feelings
• Identifying feelings in others
• Victim stories in the form of victim cams
• Identification of thinking errors

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Outline of SBP Treatment

• Managing impulses
• Social skills training
• SUDS Seemingly important decision
• Thinking error avoidance
• Learning about own triggers
• Coping skills and mechanisms
• Understand sexual offenses, patterns and behavior
• Victim cams
• Sexual timeline
• Thinking error examples
• Sexual offense assignments

21
Outline of SBP Treatment

• Understand cycle and dynamics of sexual offending
  
• Identifying triggers and stressors
• Cycle and build-up
• People, situations and activities to focus on and
  those to avoid
• Relapse prevention skills
• Acting on feelings or internal state
• Use of SUDS to stay safe
• Personal rules for safety
• Demonstrated use of protective skills and
  mechanisms
• Healthy sexuality and sexual relationships

22
Outline of SBP Treatment

• Individual therapist
• Customized treatment vs. group therapy which
  does not always have time to focus on individual
  issues
• Preparation of major assignments which are passed
  off in group therapy
• Family therapy, including reunification and
  clarification
• Most of the heavy lifting as it relates to
  treatment occurs in group
• Demonstration of skills and insight
• We have two groups weekly which are two hours
  long
• Individual therapy at least one hour per week

23
TFM and Assessment

• Current standards emphasize the importance of
  documentation and specific descriptions of the
  offense
• ". . .sex offenders tend to lie about their
  offenses and are unreliable and deceptive in
  their verbal reports" (Dougher, 1995)
• Police reports

24
TFM and Assessment

• Avoid developing assessments based on just verbal
  reports from parents and offending youth
• Gather multiple sources of information
• Parents or guardians of juveniles should be
  involved in the assessment and in the treatment
  process (Morenz and Becker, 1995)
• Comprehensive assessments should include clinical
  interviews with the juveniles and family members
• Evaluators should review victim statements,
  juvenile court records, mental health reports,
  and school records as part of their assessment
  (Becker and Hunter, 1997)

25
TFM and Assessment

• Psychological tests add a "critical dimension" to
  comprehensive evaluations of juveniles who have
  sexually offended (Kraemer, Spielman, and
  Salisbury, 1995)
• Sexual Behavior Risk Assessment a 16 hour
  standardized assessment developed by NOJOS

26
TFM and Assessment

• Thorough assessment is critical because
• Clinicians are correct in judging recidivism 50
  of the time same as chance
• Reduces time in treatment
• Polygraph motivates youth to be more honest about
  sexual history and offenses

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Assessment Tools

• The Estimate of Risk of Adolescent Sexual Offense
  Recidivism (ERASOR)
• Juvenile Sex Offender Assessment Protocol-II
  (J-SOAP-II)
• Polygraph Testing
• Abel Assessment for Interest in Paraphilias
• Others

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The Estimate of Risk of Adolescent Sexual Offense
Recidivism (ERASOR)

• Empirically guided checklist designed to assist
  clinicians to estimate the short-term risk of a
  sexual re-offense for youth aged 1218 years of
  age
• Provides objective coding instructions for 25
  risk factors (16 dynamic and 9 static)
• Preliminary psychometric data (i.e., inter-rater
  agreement, itemtotal correlation, internal
  consistency) were found to be supportive of the
  reliability and item composition of the tool
• Ratings significantly discriminated adolescents
  based on whether or not they had previously been
  sanctioned for a prior sexual offense

29
Juvenile Sex Offender Assessment Protocol-II
(J-SOAP-II)

• Checklist to aid in the systematic review of risk
  factors that have been identified in the
  professional literature as being associated with
  sexual and criminal offending
• Designed to be used with boys in the age range of
  12 to 18 who have been adjudicated for sexual
  offenses
• Can be used with non-adjudicated youths with a
  history of sexually coercive behavior

30
Polygraph Testing

• Use of polygraph tests in treatment programs for
  juveniles who have been sexually abusive is
  increasing (National Adolescent Perpetrator
  Network NAPN, 1993)
• Facilitates more complete disclosures of sexually
  abusive behaviors and to monitor compliance with
  treatment

31
Polygraph Testing

• Research regarding the reliability and validity
  of the polygraph for assessing juveniles who have
  committed sex offenses is very limited (Hunter
  and Lexier, 1998
• We use polygraphs at the beginning of treatment
  to evaluate the youth sexual behavior timeline,
  number of victims and severity of the offenses

32
Other Assessment Tools

• Phallometric assessment is a direct measurement
  of an individual's sexual arousal to deviant
  behavior
• Potential ethical concerns using phallometric
  assessment with juveniles (Bourke and Donohue,
  1996 Cellini, 1995)
• Abel Assessment for Interest in Paraphilias (Abel
  Screening, Inc., 1996) is significantly less
  invasive than phallometric assessment, and
  research conducted by the test developers has
  shown good results
• An independent study of the Abel Assessment's
  reliability and validity raised questions about
  the use of this assessment approach with
  juveniles (Smith and Fischer, 1999)

33
Clinical Treatment

• Therapists are experts who provide critical
  information
• Must be consulted as a valuable part of the
  treatment team
• Expert but not the decision-maker

34
Clinical Treatment

• Consultants decide how to mitigate risk
• Clear understanding of who makes the final
  decision
• Either program director, consultant or therapist
• Recommend that it be someone who is an expert in
  TFM

35
Clinical Treatment

• Therapists make decisions concerning safety
• Do not let therapists take control of treatment
  by citing safety issues
• Therapist wants to take away cell phone because
  the youth may make calls to sex lines is not a
  safety issue
• Youth is in cycle and must be limited in
  movement is not safety

36
Written Assignments

• Clinicians assign
• Timeline of sexual history
• Definitions of sexual terms
• Victim clarification assignments
• Thinking errors
• Assault characteristics
• Seemingly Unimportant Decision (SUD) assignments
• Journals with arousal logs
• Treatment providers follow-up, provide feedback
  and reinforces

37
Family Teachers and Treatment Parents

• Training on working with sex offenders
• Dynamics
• Risk factors
• How clinical treatment is completed
• Reunification/clarification
• The importance of skills for treatment

38
Family Teachers and Treatment Parents

• How to support clinical work
• Follow-up on assignments
• Normalizing sexual experiences
• Reports aberrant behavior and deviant thinking

39
Family Teachers and Treatment Parents

• No joking about sex offender treatment or
  assignments
• Nervous and embarrassed
• Locker room mentality
• Use appropriate language
• Body parts
• Sexual behavior
• Pornography
• Family meeting on healthy sexuality and education
  just as with sexual victims

40
Program Mechanisms

• Risk Management protocols
• Clinicians need to external/objective measures to
  assess risk
• Yearly or bi-yearly review of incidents and an
  assessment of how to manage future risk

41
Program Mechanisms

• Important to teach youth to identify skills and
  coping mechanisms they can use to exit cycle and
  manage impulses
• Allow youth to choose skills to help them in sex
  offender treatment

42
Girl Rule

• Standards for acceptable conduct with individuals
  which have potential for a sexual relationship
• Primarily for the family teachers and treatment
  parents
• Emphasize normative behavior, integrating safety
  and treatment

43
Working with Schools

• Provide customized assessments from clinician
• Train family teachers and treatment parents how
  to interact with school officials
• Never call school first with an issue or problem
• Pre-teach family teachers about how to
  communicate information
• Realize that school officials see your youth as a
  risk

44
Lesson Learned

• Address thinking errors
• Resistance of agencies to label children
  offenders and instead call them reactive may be
  appropriate for 12 years and younger and if they
  have been victims
• Cannot have these children with other children

45
Lesson Learned

• Moved all our youth out of foster care and group
  homes
• We had offenders in treatment foster care, just
  didnt say, then made them part of our continuum
  in NOJOS
• Mixed offenders with non-offenders (still see
  agencies who do this)

46
Lessons Learned

• Considerations
• Polygraph your youth and their timeline
• Know the pornography that arouse your youth
• Define pornography, sexual content, mature
  information, etc.
• Clarification and reunification before home visits

47
Lessons Learned

• Safety issues decided by therapist but dont let
  them cite safety issues to override your program
  and take it away from skill building
• Safety is important, yearly risk assessment as a
  team, barriers are critical
• No children in home

48
Lessons Learned

• Safety plans
• Family teachers need to own treatment, therapist
  needs to own the sexual offending psychodynamic
  parts of treatment
• Therapists are not trained in the model and want
  to develop their own program rather than learn TFM

49
Lessons Learned

• Avoid integrating programs
• Integration of school, home and therapy stalled
  treatment
• Work together on issues and sharing behavioral
  information
• Combining motivation systems between three
  programs will frustrate and distract youth
• Need to be successful in each domain to progress
• Dont let your clinicians or treatment providers
  tell the school what to do

50
Lessons Learned

• Normalize sexual behavior-dont teach them to
  look away
• Teach them skills to manage deviant fantasies
• Need perspective on healthy sexuality

51
Lessons Learned

• Healthy masturbation
• Family teachers need to be able to teach about
  sex, sexual relationships and appropriate sexual
  behavior

52
Suggestions

• Groups need to be male therapist with female or
  male
• Perception among referrers that female therapists
  cannot help youth like male therapists
• Can use Pathways book Pathways A Guided Workbook
  for Youth Beginning Treatment (1996) by Timothy
  J. Kahn

53
Suggestions

• Need objective measures for treatment
• Erasor and J-Soap can be used objective measures
  for treatment
• Clinical judgment has been demonstrated to be 50
  accurate regarding will/or will not re-offend.

54
Program Completion and Aftercare

• Graduation, completion and participation
• Graduation-completed program and behavioral
  indicators suggest internalizations of skills
• Completion-completed program assignments but some
  behavior suggests that internalization is not
  complete

55
Program Completion and Aftercare

• Graduation, completion and participation
• Participation-program uncompleted
• Youth moving to intensive out-patient
• Youth moving to another program
• Can be difficult to make recommendations to the
  military or programs like Job Corps

56
References

• Righthand, S Welch, C (2001) U.S. Department of
  Justice, Juveniles Who Have Sexually Offended -
  A Review of the Professional Literature
• Chaffin, M. et al., (2007) Association for the
  Treatment of Sexual Abusers, Report of the Task
  Force on Children with Sexual Behavior Problems
• U.S. Department of Justice (2001) Juveniles Who
  Have Sexually Offended - A Review of the
  Professional Literature
• Timothy J. Kahn (1996) Pathways A Guided
  Workbook for Youth Beginning Treatment