Working with Young People who Sexually Abuse

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Working with Young People who Sexually Abuse

• Dr James Bickley

The Lucy Faithfull Foundation
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Assessment Process
REFERRAL
Meeting with referrer
EXIT
INITIAL ASSESSMENT MEETING
EXIT
PSYCHOMETRICS
EXTENDED ASSESSMENT
INITIAL FORMULATION
EXIT
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Programme outline
Pre-intervention
Sexually Abusive Behaviours Element
Needs Review
Impact of sexually abusive behaviour
Sexuality Sexual Knowledge
My view of myself, others the world
Managing my feelings behaviours
My relationships with others
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Management of Programme Pitfalls in Juvenile Sex
Offender Treatment

• Wieckowski, E., Grant, C.R.
• Hodges, C.E. (2002)

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The Conceptual Problem-Solving Model

• a systematic approach for helping professionals
  identify and manage pitfalls that occur in
  treating juvenile sex offenders

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The 4 steps of the conceptual problem-solving
model

• Monitoring with awareness
• Identification of the pitfall
• Application of the intervention strategies
• Modification of the intervention strategies

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Programme Pitfalls in Juvenile Sex Offender
Treatment

• One-size-fits-all treatment approach
• It worked for one, itll work for all
• Compartmentalisation
• Each treatment piece is a separate unit, no
  reason for the juvenile to know how it all fits
  together
• Sexualising all juvenile offender behaviours,
  thoughts and feelings
• Sometimes a cigar is just s cigar

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Programme Pitfalls in Juvenile Sex Offender
Treatment (contd.)

• Inadequate screening and selection of juveniles
• sure, well take him into the programme
• Insufficient measurement
• Who needs data anyway
• External controls at the expense of
  self-management
• We gotta keep him in handcuffs all the time!

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Programme Pitfalls in Juvenile Sex Offender
Treatment (contd.)

• Complacency among staff
• were pretty good, no reason to change anything
• Countertransference
• I hate that kid
• Under-utilisation of front line staff
• Who needs them anyway
• Staff burnout
• Im fine, no really Im fine!

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Pitfall 1 One-size-fits all treatment approach

• Warning signs of a one-size-fits all approach
• Treatment plans for all offenders look very
  similar
• Juveniles address issues that are not significant
  to their offence dynamics
• Professionals superficially address certain
  treatment issues as part of a standard treatment
  protocol
• Professionals unable to employ clinical judgement
  and creativity in developing treatment plans
• Professionals adopt treatment techniques that
  they are not comfortable with, or are not in
  their area of expertise

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SCHEMATIC OF CBT APPROACH
RELAPSE SKILLS
SOCIAL COMPETENCE
OFFENCE PROBLEMS
DENIAL
Recognising risky situations Development of
strategies to deal with risk
Minimisation Denial of seriousness Justifications
Denial of responsibility
Self esteem problems Intimacy deficits Attachment
problems Assertiveness difficulties Poor
management of emotions Problems solving deficits
Patterns of dysfunctional thinking Lack of victim
empathy Emotional over/ under identification
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But is this approach suitable for all offenders?

• In terms of the implicit assumptions it has
  about the offence process taken from the classic
  RP model of offending
• And what should be undertaken in treatment
• How well does it fit with what we know about some
  offenders

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RP model that has influenced sex offender
treatment suggests that

• There is a single process of relapse which is
  that negative events or mood states are the major
  precursors of relapse , i.e. in Wolfs
  description of the offence process
• In treatment offenders should identify potential
  high-risk situations or other possible threats
  to abstinence, and then develop the appropriate
  skills to prevent relapse
• This approach also emphasises that problems are
  in part due to skills deficits
• Therefore in treatment it is necessary to deal
  with such skills deficits

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However therapists know that this is not always
the case

• although some sexual offences are associated with
  self-regulatory failure
• Others involve careful and systematic planning,
  accompanied by positive emotional states
• And offenders do not have to overcome any
  internal inhibitions

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Pitfall 1 One-size-fits all treatment approach

• Intervention Strategies
• Assess the strengths and weaknesses of the young
  person
• Develop a good understanding of the young
  persons individual offence dynamics
• Examine the young persons relevant cultural/
  environmental context
• Be creative in determining methods that can be
  used to help attain treatment goals
• Use supervision to support clinical judgment that
  certain treatment issues may not be applicable

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Assessment Process

• A framework for individual conceptualisation

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Assessment Process

• Information Gathering
• Details circumstances of offending behaviour
• Formulation
• Understanding of how behaviour occurred how it
  developed over time
• Statement of risk
• The likelihood that behaviour will continue
• Recommendations for treatment
• Outline of treatment needs

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Assessment Framework

• Part I Details of offence background
  information
• Part II Current presentation
• Part III Environmental conditions

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Details of offence background information

• Details of index offence/alleged abuse
• Family composition, history functioning
• Developmental, medical educational history
• Psychosexual, relationship social behaviour
  history
• Criminal forensic history

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Current presentation

• Presentation
• Mental state
• Cognitive functioning
• Motivation to address offending behaviour

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Environmental conditions

• Supervision monitoring
• Accommodation
• Support/information network

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Assessment Framework

• Personal predisposing factors
• Biological
• Psychological
• Interpersonal

• Contextual predisposing factors
• Parent-child factors
• Exposure to family problems
• Stresses in early life

• Personal maintaining factors
• Biological
• Psychological
• Interpersonal
• Contextual maintaining factors
• Family system
• Parental/carer
• Environmental
• Treatment system maintaining factors
• Individual/family
• Professional
• Environmental

• Personal protective factors
• Biological
• Psychological
• Interpersonal
• Contextual protective factors
• Family system
• Parental/carer
• Environmental
• Treatment system protective factors
• Individual/family
• Professional
• Environmental

Precipitating Factors
Sexually Abusive Behaviour
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Clinical Formulation

• A brief statement of the central problem(s)
• Explanation of how they developed based on
  salient points from previous sections of the
  report
• Reference made to predisposing, precipitating and
  maintaining factors
• Protective factors and family strengths that have
  a bearing on prognosis should be mentioned

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Recursive Formulation
Make or modify formulation
Plan interview agenda select tests to check
accuracy of formulation
Conduct interview administer tests
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Pitfall 2 Compartmentalising Treatment

• Warning signs of compartmentalisation
• Young person has a limited understanding of how
  to apply the information they learned in
  treatment to interrupt their offence cycle
• Young person and professionals have difficulty
  seeing how treatment issues relate to, and impact
  one another
• Young person has difficulty generalising the
  information to other sexual and non-sexual
  situations
• Young person recites back information, but has
  difficulty conceptualising how it fits into a
  comprehensive relapse prevention strategy

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Therapeutic Contracting

• A shared understanding!

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Pre-intervention

• Boundaries expectations
• Gains Losses
• The change process Managing Uncertainty
• Managing difficult feelings
• Therapeutic contracting A shared understanding
• Thoughts, feelings and what we do Introduction
  to the CBT approach

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The cost-benefit analysis
Costs of change Benefits of staying the same
Benefits of change Costs of staying the same
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The Cycle Of Change(Prochaska and DiClemente)
Exit 3 Stable, successful change
Action
Maintenance
Exit 1 Choosing not to change
Determination
Relapse
Contemplation
Exit 2 Giving up trying
Entry point
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About Me
About Me I tend to keep my problems to
myself About my Interests Hobbies I am
interested in cars About things that have
happened in my life I fell out a tree when I was
8 and was knocked out About my Offences I was
found guilty of attempting to rape my cousin Ryan
(aged 6)
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About My World
About My Family Dad left when I was 7 Ive not
seen him since About My Friends
Relationships I get on better with adults than
people my age About School or Work I was always
in trouble at school About where I live The
neighbours dont talk to us anymore
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What might we want to change?
About Me Finding it difficult to talk about what
Ive done Not thinking before I do things Not
keeping my feelings bottled up About My
World Having few friends my own age Arguments
with mum
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What might we use to help?
About Me Regretting what I have done and not
wanting to offend again I am good woodwork and
fixing things About My World Mum wants me to get
help and will support me I get on well with my
Nan, I can talk to her about my problems Chance
of a work-based training placement
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What does the programme involve how will it
meet my needs?
Sexually Abusive Behaviour Element Aim To help
challenge the attitudes, beliefs and behaviours
which led to and maintained your offending Which
of my needs will it address To learn why what I
did was sexually abusive To help me take
responsibility for my behaviour To spot and argue
against thinking that helped me to believe it was
ok, or not my fault To help me become more aware
of the steps that led up to my offending
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Introducing the CBT approach
What we do

             
How we feel
What we think
Behaviour is just the tip of the iceberg!
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Pitfall 2 Compartmentalising Treatment

• Intervention Strategies
• Relate the treatment objectives to each other
• Have the young person apply each treatment issue
  to both sexual and non-sexual situations
• Have the young person find similarities among
  objectives
• Instruct the young person to identify ways each
  treatment issue impacts the other treatment issues

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Pitfall 3 Sexualising all juvenile offender
behaviours, thoughts and feelings

• Warning signs
• Staff focus only on the sex offender role of
  the young person
• Young person decreases his disclosure of personal
  information adopting a defensive stance
• Young person has difficulty explaining normal
  sexual behaviour
• Presents himself as asexual, reporting little or
  no sexual thoughts or urges

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Pitfall 3 Sexualising all juvenile offender
behaviours, thoughts and feelings

• Intervention Strategies
• Look at evidence that the young persons
  behaviour is offence orientated
• How might other treating professionals view the
  same actions, thoughts and feelings
• Determine the similarity between the young
  persons questionable behaviour, thoughts, or
  feelings, and his offending pattern and known
  distorted world-view
• Determining whether this is a high-risk situation
  for the young person

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Offence-Specific Interventions

• The role of the offence account

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Offence-Specific Components

• Module I Sexually abusive behaviour
• Module II My sexually abusive behaviour
• Module III Changing my sexually abusive
  behaviour (developing a new life plan)

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Sexually Abusive Behaviour

• What is sexual abuse?
• Distinguishing between appropriate and
  inappropriate sexual behaviour
• The role of sexual thoughts (fantasies)
• Identifying thinking that supports sexual
  offending

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My Sexually Abusive Behaviour

• Offence account (revisited)
• Offending sequence (storyboards footsteps)
• Life context of offending pattern
• Responsibility for offending (Finklehors
  pre-conditions)
• Consequences of offending

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Finkelhors Four Pre-conditions
Motivation
Victims Resistance
External Inhibitors
Internal Inhibitors

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Changing My Sexually Abusive Behaviour

• Challenging offending linked thinking
• Taking control of my inappropriate sexual
  thoughts
• Recognising offending-linked behaviours
• Footsteps out

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Pitfall 4 Inadequate screening and selection of
juveniles

• Warning signs
• The range of young people is too broad (i.e. age,
  offence type, IQ etc.)
• The treatment services do not match the existent
  population
• Excessive acting out and decreased trust toward
  staff or peers
• Selection of young people only guided by monetary
  considerations
• Programme staff giving in to outside pressure to
  admit inappropriate candidates

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3-step system of screening

• Screening criteria
• Identify good referral candidates (e.g. age,
  gender, mental health status, intelligence)
• Selection criteria
• Identify which young people should enter the
  programme (this process tends to be more
  subjective, e.g. personality, motivation)
• Maintenance criteria
• Minimal requirements the young person needs to
  attain to remain on the programme

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Pitfall 4 Inadequate screening and selection of
juveniles

• Intervention strategies
• Consistently examine and refine criteria to match
  the changing needs of the programme, juveniles
  and community
• Clearly state programme criteria to referring
  agencies, court officials and community
  professionals
• Do not be afraid to say no to inappropriate
  referrals
• Examine what is guiding selection procedure.
  Focus on ensuring a good fit rather than
  conceding to community, political or monetary
  pressures

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Pitfall 5 Insufficient measurement

• Warning Signs
• Basic data is not available upon request
• Staff do not engage in research efforts
• Data stored on hard copies, but not entered into
  a computer
• Measurement system is too complicated to be used
  effectively, which encumbers data entry, access,
  and interpretation

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4 components of measurement

• Demographics
• Basic information about the young person, family,
  school, medical history etc.
• Testing
• Psychometrics (general offence-specific)
• Treatment
• Offence details/disclosures
• Progress through treatment
• Follow-up
• Adjustment to the community
• Recidivism

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Pitfall 5 Insufficient measurement

• Intervention strategies
• Block out time in staff members schedule to
  collect, enter, and analyse data
• Train staff to use testing materials that produce
  useful data
• Train staff to accurately interpret and analyse
  data
• Employ college interns (students) to assist in
  objective periodic analysis

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Pitfall 6 External controls at the expense of
self-management

• Warning signs
• Young person only parrots treatment information,
  but have difficulty explaining in their own words
• Their behaviours regress when they believe no one
  is monitoring them
• They become overly dependent on staff, lacking
  confidence when not constantly encouraged
• They become institutionalised and find it
  difficult to function without a high level of
  supervision and structure
• They have difficulty making decisions

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Pitfall 6 External controls at the expense of
self-management

• Intervention strategies
• Create a treatment environment whereby the real
  world is safely approximated in daily living
• Increase the young persons self-confidence in
  their application of material learned in
  treatment
• Avoid chasing behaviours that unrealistically
  exaggerate the young persons lapses
• Avoid doing the treatment work for the young
  person
• Assist the young person to develop a support
  network to act as a safety-net and a resource as
  he practices his newly learned skills

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Pitfall 7 Under-utilisation of front line staff

• Warning signs
• Front line staff do not feel they are part of the
  programme, they are not involved in decisions
  making
• Communication between clinical an front line
  staff is minimal
• The young person is able to split clinical and
  front line staff
• Evidence of passive aggression between front line
  staff and other professionals in the programme
• Front line staff become apathetic and believe
  they cannot make a difference

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Pitfall 7 Under-utilisation of front line staff

• Intervention strategies
• Remind front line staff they are an integral
  component of the treatment programme
• Ask them for feedback and input on a regular
  basis and involve them in the decision making
  processes
• Train them about each treatment component so they
  can help monitor the young persons progress in
  treatment
• Share general information about each young
  persons offence dynamics, so they can help
  identify lapses

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Pitfall 8 Complacency among staff

• Warning signs
• An escalation in significant programmatic
  problems
• Lack of enthusiasm for the work
• Sessions are missed or shortened
• Professionals are not aware of current trends in
  research and practice
• The programme structure has not significantly
  changed to keep up with research and literature

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Pitfall 8 Complacency among staff

• Intervention strategies
• Develop a programme review committee composed of
  internal and external professionals
• Attend conferences and regularly talk to other
  professionals in the field
• Address minor problems as they develop within the
  treatment programme
• Increase morale, motivation, and enthusiasm among
  staff, so they are mentally ready and eager to
  look for potential pitfalls

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Pitfall 9 Countertransference

• Warning signs
• Difficulty remaining objective toward the young
  person
• Evidence of a strong attraction or dislike for
  the young person
• The professional spends less or more time with
  the young person compared to others
• Difficulty engaging or disengaging in a
  therapeutic relationship with the young person
• The young person is able to push your buttons

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Unconscious Processes Working with Young People
who Sexually Abuse (Bankes, 2002)

• Victimised reactions
• I think you can get shocked sometimes, like a
  real kick in the stomach
• Persecutory reactions
• Over-controlling
• In order to not let myself get too vulnerable I
  have to take charge and be directive
• Blaming
• I just thought how could you do this? to a 7
  year-old girl? She trusted you and you knew, you
  mustve know what you were doing. There is no
  way you can blame the child for it, you are older
  and much wiser

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Unconscious Processes Working with Young People
who Sexually Abuse (contd.)

• Or confrontational
• I was completely pissed off with the young person
  and Id had enough and I thought Im doing all
  the work here. So I behaved like mum or a
  teacher or any of these other people who have
  given him a negative response
• Rescuing reactions
• Collusion
• I think maybe I was anxious that he might end
  being upset and I dont want to hear him being
  upset

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Unconscious Processes Working with Young People
who Sexually Abuse (contd.)

• Overidentification
• Yes, I guess probably there is a bit of, you
  know, I could be John sitting there sometimes and
  getting quite angry (in professionals meetings).
  Perhaps I take some of his feelings with me
• Or by trying harder
• You become practically involved in their lives as
  well as emotionally, its extra to the
  therapeutic relationship

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Pitfall 9 Countertransference

• Intervention strategies
• Assess your own emotions, and what they are
  telling you. If he elicits certain feelings or
  reactions from you, he likely did this to other
  individuals in the past
• In some cases, share feelings and thoughts that
  were elicited by the young person, and examine
  them with him
• Discuss your thoughts and feelings with
  colleagues as a way of addressing
  countertransference objectively
• Refer the young person to another professional if
  the countertransference interferes with the
  therapeutic relationship

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Pitfall 10 Staff burnout

• Warning signs
• Expectations are too high, including the need to
  cure offenders and blaming self for recidivism
• Avoid meeting with offenders or doing the work
• Decrease in enthusiasm and motivation at work
• Work interfering with home life
• Obsessively question own sexual behaviours,
  thoughts and feelings
• Unrealistically hyper-vigilant about sexual abuse

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Pitfall 10 Staff burnout

• Intervention strategies
• Set realistic expectations for treatment outcome
• Place responsibility for treatment progress onto
  the juvenile
• Limit number of sex offender clients
• Talk with colleagues who work with sexual
  offenders
• Participate in conferences to revitalise self
  with new treatment methodology
• Use relaxation and stress management techniques
• Use humour with self and colleagues