VSOTA 2015_Therapeutic Alliance_L Marshall_FINAL

2015-04-04
Establishing an effective
therapeutic alliance in the
treatment of sexual offenders
Introduction





Liam E Marshall, PhD
Waypoint Centre for Mental Health Care
&
Rockwood Psychological Services


www.waypointcentre.ca
www.rockwoodpsyc.com
Introduction



First therapeutic process article: Beech and
Fordham’s (1997) study of group cohesiveness
Most treatment programs for sexual offenders
adhere to highly specified procedures and
detailed manuals which are highly
psychoeducational (Green, 1995; Robinson &
Porporino, 2001; Cordess, 2002)
A highly aggressive, confrontational approach
has been seen as the only way to derive
behavioral change (Salter, 1988; Wyre, 1989)
Therapeutic Alliance
Client Factors
Therapist Factors
Process Factors
Our Approach
Efficacy
PLEASE NOTE THAT THESE SLIDES MAY
CHANGE HOWEVER ARE
REPRESENTATIVE OF PRESENTATION
Literature Review and Research
The therapist’s style, the client’s
perceptions of the therapist, and the
alliance between client and therapist
influence treatment effectiveness (25% of
the variance)
 70% of therapeutic effects are due to
factors common across all approaches
(Wampold, 2001)

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Therapeutic Alliance/Atmosphere
The therapist’s interpersonal characteristics
and techniques in combination with the
client’s perceptions of the therapist = the
therapeutic alliance.
 Seen as the context of therapeutic change.
 Key component is collaboration between
client and therapist.

Therapeutic Alliance



(Luborsky, Barber, & Chris-Christoph, 1990; Marshall et al., 2001; Safran
& Murran, 1996; Matt & Navarro, 1997)

Strict adherence to treatment manuals
without establishing a good therapeutic
alliance is not effective. (Fernandez & Serran, in press)
5
Poor outcomes show greater evidence
of negative interpersonal process in the
therapeutic relationship.
particularly hostile and complex interactions
between therapist and patient.
Ratings of the therapeutic alliance have
been shown to predict dropouts from
treatment.
(Marshall et al., 2001.)
6
Features that Enhance and Reduce
Treatment Effectiveness
WHAT WORKS?
Features that Reduce Treatment
Features that Enhance
Effectiveness
Treatment Effectiveness
 Aggressive Confrontation
 Empathy
 Rejection
 Warmth
 Manipulative/Lack of
 Respect
boundaries
 Genuineness
 Lack of interest
 Supportive
 Critical
 Directive
 Sarcastic
 Flexible
 Hostile/Angry/Rigid
 Encourages Participation  Cold/Unresponsive
 Rewarding
 Dishonest
 Judgmental
 Attentive
 Authoritarian
 Trustworthy
 Defensive
 Use of humor
 Emotionally Responsive  Nervous/Uncomfortable
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Outcome Determinants

 Refusers
 Flooding
therapy
 Dropouts
 High
rates of dropouts in
offender programs
 Gets
 How
it
much is enough treatment?
GOVERING PRINCIPLES OF TREATMENT

GOVERING PRINCIPLES OF TREATMENT
Needs:
 Target empirically established criminogenic
needs
 Address other targets as they relate to
motivation for and engagement in
treatment, e.g., Self-Esteem, feelings of
personal distress, major mental illness,
(Bonta & Andrews, 2007)
 Significant predictor in Hanson et al.
(2009)
Risk:
 Allocate
resources (treatment, release,
and community supervision)
differentially to high, moderate & lowrisk offenders
 In
cases of limited resources, treat
highest risk offenders
 Not
a significant predictor in Hanson et
al. (2009)
GOVERING PRINCIPLES OF TREATMENT
Specific Responsivity
 Adapt approach to each individual’s style/culture
 Adapt approach to each individual’s day-to-day
fluctuations
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GOVERING PRINCIPLES OF TREATMENT
General Responsivity:


Often seen as requiring CBT but not necessarily
Core Correctional Practices
 Select therapists for therapeutic qualities
 Empathy, warmth, rewarding, prosocial modeling, being
respectful
 Train therapists to
employ these qualities
ensure enactment of these
WHAT THEN IS EFFECTIVE?
MUST:
1. Address criminogenic targets
2. Employ empirically sound procedures
3. Deliver treatment in known effective
ways
 Supervise therapists to
qualities
 Significant in
Hanson et al. (2009)
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Criminogenic Issues in Sex Offenders
Sexual factors
- sexual preoccupation
- sexual interests in children
- Sexual interest in violence
Cognitive factors
- emotional congruence with
children
OVERALL OUTCOME FROM INTERNATIONAL
TREATMENT PROGRAMS (Hanson, et al., 2002)
CBT & Systemic Programs (N = 15)
- hostility towards women
Relationship problems
- lack of concern for others
- lack of intimacy
- insecure attachment
- emotional loneliness
- offence supportive attitudes
Self-regulation issues
- emotional dysregulation
Low self-esteem/shame
Sexual
Recidivism
General
Recidivism
Treated =
9.9%
32.3%
Untreated =
17.3%
51.3%
Mean follow-up = 46 months
15
16
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Number of ACEs
CLIENT FACTORS
Prevalence, males only – CDCP & Others
ACE CATEGORY
CDCP
(N=7,970)
ABUSE
Messina
(N=425)
Levenson
(N=679)
Percentage reporting ACE
Emotional Abuse
7.6
*included in
53.3
Physical Abuse
29.9
20.2
42.2
Sexual Abuse
16.0
8.5
38.0
Emotional Neglect
12.4
20.0*
37.6
Physical Neglect
10.7
4.9
15.9
Mother treated violently
11.5
49.4
24.0
Household substance abuse
23.8
53.6
46.7
Household Mental Illness
14.8
NR
25.9
Parental separation or divorce
21.8
44.6
54.3
Incarcerated household member
4.1
41.6
22.6
NEGLECT
HOUSEHOLD DYSFUNCTION
# of ACEs
Women
(CDCP)
Men
(CDCP)
Levenson
et al., 2014
0
34.5%
38.0%
15.6%
1
24.5%
27.9%
13.7%
2
15.5%
16.4%
12.8%
3
10.3%
8.6%
12.3%
4+
15.2%
9.2%
45.7%
What has been found?
• CDCP: N = 17,337
– ↑ACEs = ↑Physical & Mental Health problems
– ↑ACEs = ↑ risk for substance abuse, suicide
attempts, depression, smoking, obesity, DV, sexual
promiscuity
• Levenson et al.:↑ACEs r
– younger victims
– ↑ nonsexual arrests
– ↑ violence in offence
– ↑risk for reoffending
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Deinstitutionalization
600
Per 100 000 in the US
500
• Availability of treatment for psychotic illness
(CPZ in late 1950s)
• Civil rights movement extended to the
mentally ill
400
300
200
– Right to humane treatment by trained staff
• Increased cost of treatment in long-term institutions
resulting in closure of chronic beds
100
19
28
19
32
19
36
19
40
19
44
19
48
19
52
19
56
19
60
19
64
19
68
19
72
19
76
19
80
19
84
19
88
19
92
19
96
20
00
0
Mental Hospitals
Harcourt BE. From the asylum to the prison: rethinking the incarceration revolution. Texas
Law Review, 2000; 84:1751-1786.
Transinsitutionalization
– Right to freedom
• More strict civil commitment criteria
• Patient choice to receive treatment in hospital or out
of hospital
Reasons for Transinstitutionalization
700
• Inadequate resources in community to assist the
chronically ill
• Some chronically ill too ill for community
• Limited hospital beds
600
500
400
– Rejection of refractory chronically ill (incl MR)
– Short stays prevent true stabilization
– Guarding beds for ‘acceptable’ patients
300
200
• No crime (especially sexual crime)
• No severe violence, substance or personality disorders
• No homeless/ itinerant
100
0
19
28
19
32
19
36
19
40
19
44
19
48
19
52
19
56
19
60
19
64
19
68
19
72
19
76
19
80
19
84
19
88
19
92
19
96
20
00
Per 100 000 in the US
Reasons for Deinstitutionalization
Mental Hospitals
Prison
• Criminalization of deviant behaviours motivated by
illness
• Konrad, N. (2002) 'Prisons as new asylums', Current Opinion
in Psychiatry, 15:pp. 583-87.
Harcourt BE. From the asylum to the prison: rethinking the incarceration revolution. Texas
Law Review 2000; 84:1751-1786.
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Transinstitionalization

In 2002, there were 12,700 inmates in Canadian
penitentiaries (Federal)
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97% were men
84% of inmates have a current DSM-IV diagnosis
Substance-related highest at 75%
Excluding substance, 43% have a psychiatric
disorder
Inmates have an 8% lifetime prevalence of psychotic
disorders
The suicide rate is 3.7x higher than the general
population
Resistance in Sexual Offenders
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
HMPS - Mann & Webster, 2001
3 Groups

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

Admit – Enter Treatment
Deny – Refuse Treatment
Admit – Refuse treatment
Conducted Interviews
Canadian Journal of Public Health 2004, Supplement 1
Treatment refusal rates

Across all areas of medicine, including
psychotherapy, between 1/3 and 1/2 of patients do
not comply with the treatment that is recommended
or prescribed to them (Melamed & Szor, 1999).

Sex offender treatment refusal rates in HMPS
treatment establishments averaged 52%, range
between 8% and 76%.
Resistance in Sexual Offenders
System Factors
 Lack of trust in professionals
 Bad experiences
 System undermines treatment
Courtesy of HMPS (Mann et al, 2001)
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Resistance in Sexual Offenders
Resistance in Sexual Offenders
Psychological characteristics
Social and family system
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
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Reactance to pressure to enter treatment
Lack of insight into own problems
Future-focused coping style – absent in
refusers
Courtesy of HMPS (Mann et al, 2001)

Cultural issues

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Refusers concerned about lack of sensitivity to
cultural issues
Family factors

Refusers’ family more likely to believe offender is
innocent
Courtesy of HMPS (Mann et al, 2001)
Resistance in Sexual Offenders
Conclusions - Mann et al, 2001
Treatment beliefs and knowledge
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

Effectiveness
Side effects
Previous bad experience
Stigmatization
A significant proportion of resistance could
be reduced by some simple strategies.
 E.g.,


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More than half of refusers expressed a desire
to enter treatment that has a broader aim
than addressing offending only

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Provision of information about treatment
Focus on building rapport and trust
Involve and inform non-treatment staff
Establish Therapeutic Alliance
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Treatment Attrition, Proulx et al, 2004
Treatment Attrition
Proulx et al, 2004
Pre-treatment variables associated with
attrition
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N=284, Prison, Psychiatric, & Outpatient
Noncompleters


Institution = 18.1%
Outpatient = 38.3%

In-Treatment factors
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

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Therapeutic alliance – low commitment, low
working capacity
Family environment – high conflict
Group environment – over-control
Stages of change
Joe Harry Window

KNOWN SELF
HIDDEN SELF
Things we know about
ourselves and others know
about us
Things we know about
ourselves that others do not
know


BLIND SELF
Empathy, Antisociality, OCD, Alcoholism, Social
Self-Esteem
Coping style: distraction, Coping Using Sex
UNKNOWN SELF

Things others know about us Things neither we nor others
that we do not know
know about us
Precontemplation: people who are not
intending to take action in the foreseeable
future
Contemplation: people who are intending to
change in the near future
Action: people who are making specific overt
modifications in their life styles
Maintenance: people who are working to
prevent relapse,”a stage which is estimated to
last from 6 months to about 5 years"
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Attachment


Early experiences with parents provide
developing individuals with a template for all
future relationships (Bowlby, 1969, 1973, 1980)
Poor quality parent-child relationships set the
stage for inadequate attachment styles as adults
Attachment Issues
Attachment

(Check et al., 1985)

Adulthood
Interdependence
An inadequate attachment style often leads to
intimacy deficits and subsequent loneliness,
which is predictive of aggression toward others
Adolescence
Independence
Evidence suggests sexual offenders typically
have childhoods marked by either estrangement
from, or abuse by, their parents (Marshall & Barbaree,
1990; Marshall, 1989, 1993)
Birth to Puberty
Dependence
40
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Bartholomew’s Dimensional Model of Attachment
VIEW OF SELF
+
PREOCCUPIED
-
FEARFUL
Secure Attachment
Positive view of self, positive view of others
• Engage in therapy and easy to manage on unit
• High levels of trust in others
• Get along well with other residents
• Good problem solving
• Emotionally well-regulated
+
SECURE
VIEW OF
OTHERS
DISMISSIVE
41
Preoccupied Attachment
Negative view of self, positive view of others
• Highly anxious, often depressed
• Attention seeking and demanding
• Need approval/validation from others
• Revere staff and some other residents
• Get angry or petulant when they feel ignored
• Low self-esteem and emotionally volatile
• Expect all demands to be met now!
• Look up to charismatic others
• Easily taken advantage of by others
• Borderline Personality Disorder
• Could be sexually preoccupied
Fearful Attachment
Negative view of self, negative view of others
• Mistrustful of others
• Often described as “Loners”
• Fear rejection and hurt
• Superficial interpersonal interactions
• Want attention and comfort but find it difficult to
trust others
• Low self-esteem and dysfunctional attitudes
• High levels of psychopathology
• Devastated when they feel that others have let
them down but at the same time, expect it
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Dismissive Attachment
Client’s perception of the therapist
Positive view of self, negative view of others
• See no value in getting close to other
residents or staff
• Described as aloof, cold, and distant
• Constantly put blame for every problem on
others
• Display animosity toward others
• Prey on vulnerable residents
• Antisocial Personality Disorder

Positive correlation between clients’
perception of the quality of the
therapeutic relationship and perception
of positive outcome.
(Walborn, 1996)

These perceptions significantly influence
client compliance and predict treatment
outcome.
(Saunders, 1999)

Consequently it is not enough for
therapists to believe they are displaying
appropriate characteristics
(Schindler et al., 1983; Ryan & Gizynski, 1971; Ford, 1978; Marshall et
al., 2001.)
46
Client’s perceptions of the therapist
Greater treatment benefits generated by therapists
who are perceived as:
 Confident
 Involved
 Focused
 Emotionally engaged
 Have positive feelings toward the client
 Directive
 Persuasive
 Sincere
47
Client’s perceptions of the therapist
Therapists are relatively poor at evaluating
their own therapeutic characteristics and
style.
 In 34 of 47 studies (72%) clients’ estimates
of therapist features correlated with
beneficial treatment effects.
 Therapist ratings were related to outcome
in only 4 of 15 studies (26%).

(Free, Green, Grace, Chernus, & Whitman, 1985; Orlinsky et al.,
1994)
48
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CLIENTS’ PERSPECTIVES
(Drapeau, 2005)
1.
2.
3.
4.
5.
6.
See therapist as crucial but also value procedures
Quality of the program = the skills of the therapist
Good therapists are: honest, respectful, nonjudgmental,
available, caring, confident, competent, and persuasive,
encourage discussion, listen, display leadership and
strength, and maintain order
Do not respond to therapists who are critical, devaluing,
or confrontational
Clients want therapist to supportively challenging them
in a caring manner
Clients desire to participate in decision making (work
collaboratively) and they wish to attain mastery and feel
competent
Positive therapist features





An ability to create an appropriate alliance
with the client
Ability to generate a belief in the possibility of
change
Providing opportunities for learning
Instilling the expectation in the client that
therapy will be beneficial
Emotionally engaging clients
THERAPIST FACTORS
Features that Enhance and Reduce
Treatment Effectiveness
Features that Reduce Treatment
Features that Enhance
Effectiveness
Treatment Effectiveness
 Aggressive Confrontation
 Empathy
 Rejection
 Warmth
 Manipulative/Lack of
 Respect
boundaries
 Genuineness
 Lack of interest
 Supportive
 Critical
 Directive
 Sarcastic
 Flexible
 Hostile/Angry/Rigid
 Encourages Participation  Cold/Unresponsive
 Rewarding
 Dishonest
 Judgmental
 Attentive
 Authoritarian
 Trustworthy
 Defensive
 Use of humor
 Emotionally Responsive  Nervous/Uncomfortable
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Therapist features related to
significant treatment-induced changes
Marshall, Serran et al., 2001


Examined therapist features and their relationship to
client changes in sexual offender treatment.
Rated videotaped sessions and then related to prepost treatment changes
 Warmth
 Empathy
 Rewarding
 Directive
Results of regression analyses
Index of change
Therapist feature
R2
F ratio
p<
Victim blame
E+W+R+D
E+W
R+D
.41
.34
.39
5.09
8.01
10.01
.003
.002
.001
Minimizes aspects
of offense
E+W+R+D
E+W
R+D
.61
.55
.33
10.70
18.17
7.4
.001
.001
.002
E+W+R+D
E+W
R+D
.32
.25
.22
3.51
5.20
4.41
.02
.02
.02
Denies
responsibility
PROCEDURAL FACTORS
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DEGREE OF MANUALIZATION
No direction
Guide
Highly detailed manual
IMPLICATIONS OF THIS CHOICE

1) TARGETS
Lack of specification of
targets
Choice of targets
Fixed and specific targets
Choice
Single and specified
Dependent on each client’s
needs
Fixed number
Treatment targets repeatedly
addressed
Fully modularized
Psychotherapeutic
Psychoeducational
Collaboration
Therapist choice only57
2) PROCEDURES FOR EACH TARGET
None specified
3) NUMBER OF TREATMENT SESSIONS
Unspecified
4) STRUCTURE
Fully unstructured
5) TREATMENT STYLE
Idiosyncratic
6) CLIENT INVOLVEMENT
Client choice only
Ideal Group Climate
• Maximum benefits gained from moderate to
high levels of




59
Group Climate
Cohesion & leader support
Task orientation
Order/organization
Encouragement of personal growth

Moos’ Group Environment Scale (GES)
10 Subscales, has norms, well used










Expressiveness
Cohesion
Task Orientation
Self-Discovery
Leader control
Innovation
Anger & Aggression
Leader Support
Independence
Order & Organization
Ideal Climate Cont’d
• Outcomes
• Greater satisfaction with the group
and leader
• Members get greater benefits from
group
• Facilitates members’ learning of
specific skills, personal and
intellectual development
60
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GROUP CLIMATE
Beech & colleagues 1997; 2005
 Cohesion and Expressiveness subscales were
significantly related to the composite measure of
treatment gains
 Cohesion includes involvement, participation,
commitment to the group, and concern and friendship
for each other
 Expressiveness measures the encouragement of
freedom of action and the expression of feelings
Marshall, Serran, & Davis, 2009
 Open-ended groups - better group climate, & faster
OUR APPROACH
Treatment Approaches
Good lives model (Tony Ward et al.)
Traditional Approaches
 Psychoanalytic
 Behavioral
 Cognitive
 Relapse Prevention
 Cognitive-Behavioral
New Directions
 Risk/Needs/Responsivity (Andrews et al.)
 Good Lives Model (Ward et al.)
 Motivational Interviewing (Miller & Rollnick)
 Positive Psychology (Seligman et al.)
Primary goods:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Life: healthy/optimal functioning, sexual
satisfaction
Knowledge
Mastery: in work and play
Agency: autonomy and self-directiveness
Inner peace: freedom from turmoil and stress
Relatedness: intimate, romantic, kinship,
community
Spirituality: meaning and purpose in life
Happiness
Creativity
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Good lives model cont.
Depends: possession of internal conditions (skills
and capacities) and external conditions
(opportunities and supports)
Treatment:
1. Determine with each client his personal goals
and priorities in order to generate a specific
good lives model suitable to him
2. Assist him (if necessary) in acquiring the skills
and attitudes necessary to work toward his
goals
3. Help him identify ways in which he can create
opportunities to realize his goals
4. Work with the client to identify support people
who will assist him in realizing his goals
A POSITIVE/MOTIVATIONAL Approach

Maintains good aspects of previous
approaches –

Cognitions and behaviors are targeted
Incorporates Approach Goal, Good Lives, &
Positive Psychology theories
 Acknowledges importance of client motivation
for change
 Addresses criminogenic needs – Stable &
Acute Factors

Positive Psychology Features
Elements of a Positive Approach
What is good about life is as important as
what is bad and therefore deserves equal
attention
 Life is about more than avoiding or
undoing problems
 Strength focus – not deficits
 Hope theory




Goals, Pathways, Agency
Aim is for a more fulfilling life
Assessment



Approach


Orientation
Targets


Measures
Reports
Dynamic Risk for Recidivism Factors
Process



Groups versus Individual Treatment
Therapist Style and Characteristics
Group Process Issues
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POSITIVE/MOTIVATIONAL PROGRAM
ROCKWOOD PSYCHOLOGICAL SERVICES
MOTIVATION &
ENGAGEMENT
1. INITIAL DISCLOSURE
2. AUTOBIOGRAPHY
Goals and Optional Exercises
• Enhancing self-esteem
• Reducing shame
• Improving coping and
mood management
• Orientation to treatment
• Allow offender to tell his
perspective
69
PRIMARY TREATMENT
3. EMPATHY/VICTIM HARM
4. OFFENCE ANALYSIS
• Background Factors
• Immediate Factors
RELATIONSHIP SKILLS
 Nature and advantages of
intimacy
 Problems of loneliness
 Attachment styles
 Communication
 Jealousy
SEXUALITY
 Healthy sexual functioning
 Maximizing sexual
satisfaction
 Reducing deviant interests
o behavioural strategies
o pharmacological
interventions
FUTURE LIFE
STRATEGIES
5. MODIFIED GOOD
LIFE PLANS
• Goal setting
6. LIMITED
AVOIDANCE
STRATEGIES
 Warning signs for self
and others
7. SUPPORT GROUPS
 Professionals
 Family and friends
 Colleagues
8. RELEASE PLANS
 Accommodation
 Employment
 Leisure
Behavioural Progression Model,
Adapted From CSC
Trigger:
Trigger:
Change for the worse
Opportunity & Disinhibition
Background
Factors
Immediate
Factors
•Exposure to abuse as a
child
•Anger
•Attitudes and Goals
Supportive of offending
•Attachment and
Relationship difficulties
•Emotional self-regulation
problems
•Poor coping skills and
style
•Empathy deficits
•Increased Stress,
Anxiety, Depression,
Loneliness, Emotional
Arousability, Anticipation
•Cognitive Struggle and
Dissonance
•Escalation in emotions
•Increased substance
abuse
Offending
Post Offence
Fear
Shame
Self-Loathing
Cover-Up Attempts,
Cognitive Distortions,
Increased Immediate Factors
70
Rockwood Offender Programs





Preparatory – typically 6
weeks
Regular – typically 4
months
Deniers - typically 4
months
Maintenance - typically 3
months
Also available – Adapted
SOTP, Domestic Violence,
Anger Management, Substance
Abuse, Problem Gambling,
Hypersexuality







Open-ended
2 x 2 ½ hours/week
8-10 offenders
1 therapist in each group
Mix of all types of sex
offenders in same group
Entry to program as close
to intake as possible
No individual sessions
unless special
circumstance
Juvenile Sexual Offenders:
Risk, Recidivism, & Treatment
Liam E Marshall, Ph.D.
Rockwood Psychological Services
www.rockwoodpsyc.com
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2015-04-04
Risk Factors of Juvenile Sexual Offenders
Empirically supported:
• Deviant sexual interests
• Prior sanctions for sexual offending.
• More than one victim.
• Stranger victim.
• Social isolation.
• Uncompleted offense-specific treatment.
Other possible factors:
• Problematic parent-adolescent relationships.
• Attitudes supportive of sexual offending.
• High-stress family environment.
• Impulsivity.
• Antisocial interpersonal orientation.
• Interpersonal aggression.
• Negative peer associations.
• Sexual preoccupation.
• Sexual offending against a male victim (only applicable to male offender).
• Sexual offending against a child.
• Threats, violence, or weapons in sexual offense.
• Environment supporting reoffending
Outcome: Recidivism
Study
Sexual
Violent
Non-sexual
non-violent
Worling & Curwen, 2000
Untreated
18%
32%
50%
Treated
5%
19%
21%
Reitzel & Carbonell, 2006 (Meta-analysis, 9 studies)
Untreated
Treated
18..93%
7.37%
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Kingston, Canada, Probation Approach
to Managing Juvenile Sexual Offenders
• Low risk – diversion or minimal supervision
• Moderate risk – supervision along with sexual
offender-specific treatment
• High risk – Intensive supervision by probation
officer, reintegration assistance by community
support worker, and sexual offender-specific
treatment
• High risk & mentally disordered – Intensive
supervision by probation officer, Intensive
reintegration by specialized community support
worker, and sexual offender-specific treatment
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Rockwood Approach to Treating Juvenile Sexual
Offenders
1.
2.
Introduction
Autobiography
–
–
3.
Understanding Risk Factors
–
4.
Sexual functioning/satisfaction
Preoccupation & deviance
Future Life – GLM
–
–
–
–
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Attachment
Peers/friends/romantic
Healthy Sexuality
–
–
6.
GLM at time of offending
Relationships
–
–
5.
Genogram
Life History
What is important to you
Negotiate with client what to work on
What and who helps to achieve goals
What and who impairs achievement of goals
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2015-04-04
Core Treatment Issues
•
•
•
•
•
•
•
•
•
Self-esteem enhancement
Moving from shame to guilt
Coping
Socialization
Overcoming family issues
Attitudes
Empathy
Working with supportive family
Very little relapse prevention
EFFICACY: DOES IT WORK?
Achievement of Targets & Recidivism
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TREATMENT CHANGES IN SELFESTEEM
Treatment induced changes in intimacy
PrePostNormative
treatment treatment
mean
Child
Molesters
110.34
(13.01)
123.48
(10.01)
132.0
(21.0)
Miller’s Social
Intimacy Scale
(Miller & Lefcourt, 1982)
Pre-treatment
Post-treatment
85.31
(38.08)
93.31
(35.13)
(Marshall, Champagne, Sturgeon, & Bryce, 1996)
(Marshall, Champagne, Sturgeon, & Bryce, 1996)
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2015-04-04
CHANGES IN EMPATHY IN A SEXUAL OFFENDER
TREATMENT PROGRAM
Rockwood Psychological Services Program
Percentage of sexual offenders in each risk category
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Accident
Victim
Other Sex
Abuse Victim
Own Victim
40
Pre-treatment
279.68
(57.96)
278.28
(96.11)
178.97
(120.89)
Posttreatment
269.43
(55.21)
322.76
(59.41)
345.14
(54.04)
Normative
sample
289.25
(45.82)
345.38
(45.89)
30
20
10
0
Low
Lo/Mod
Mod
Mod/Hi
Hi
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Rockwood’s Program
Outcome for Rockwood Program - 2005
Refusers
3.8%
Drop-outs
4.2%
Completions
95.8%
Treated*
(N = 535)
Expected**
Sexual
3.2%
16.8%
General
13.6%
40.0%
Reoffence
*Mean follow-up = 5.4 years
**Based on Static-99 and S.I.R.
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2015-04-04
Outcome for Rockwood Program - 2009
Treated*
(N = 535)
Expected**
Sexual
5.6%
23.8%
Violent
8.4%
34.8%
Reoffence
THERAPEUTIC PROCESS
*Mean follow-up = 8.4 years
**Based on Static-99 (revised 2003)
Treatment Issues
(Ware, Marshall, Mann, & Marshall)
Intensity, dosage, and timing
 What is high intensity?
 What intensity?
 Treatment dosage?
 Is treatment better than
other resettlement
activity?
 Timing of treatment?
Content
 Denial/minimisation
 Need to accept
responsibility?
 Need for offence
disclosure?
 Target sexual deviancy?
Setting
 Custody v community
 Therapeutic communities?
 Support from non-therapy
staff
 Stand alone prison units?
Format
 Group v individual
treatment
 Rolling v closed groups
 Group composition
 Number of facilitators?
Gender mix?
Psychologists?
How do we do it?
Treatment Strategies
Three approaches have typically been used:
a) Confrontational approach
b) Unchallenging approach
c) Motivational approach
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2015-04-04
Confrontational Approach
Confrontational Approach
Involves challenging the client in an
aggressive manner.
 Aim is to achieve an admission of guilt and
acceptance of the problem.
 Group member may be required to accept
the label of “offender” and believe extensive
supervision and treatment is necessary.

Offenders react to confrontational
approach with resistance or passive
acceptance.
 Self-confident offenders may become
resistant and argumentative.
 Low self-esteem clients may simply
passively agree with the therapist to avoid
conflict.

Unchallenging Approach
Sees offenders as victims.
 Unconditional positive regard for clients.
 Therapists are responsible for changing
their clients and solving all their problems.
 Unchallenging therapists demonstrate
many positive therapeutic characteristics
(E.g., warmth, empathy, rewarding

Motivational Approach





Motivate change through understanding and
acceptance.
Encourage clients to view themselves as a whole
person with strengths who has engaged in an
unacceptable behaviour.
Therapists are encouraging and supportive but set
necessary limits, respond firmly, and challenge
behaviours.
A positive approach to treatment motivates clients to
make positive changes.
Therapists place responsibility for change in hands of
clients but assist clients in finding ways to make
changes.
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2015-04-04
Methods for Motivating Clients

Express Empathy
Methods for Motivating Clients

 Create
and amplify discrepancy in the client’s mind
between their distorted cognitions and the
perceptions of others; examine the consequences
of their behaviour step by step; have client outline
pros and cons of their behaviour; help client create
challenges for their own cognitive distortions.
 actively
listen without judgement, criticism or
blame. Understand client may hold onto cognitive
distortions for a reason.

Avoid Argumentation
“labeling” clients; resistance means change
strategies; do not force clients to defend their
position.
 avoid


client’s confidence in his ability to change;
give examples of distortions he has already moved
on and reinforce the change; emphasize the
importance and benefits of taking responsibility
 do
not fight it (you will lose); try reflecting questions
and concerns; have client generate possible
answers.

Ask open-ended questions
Methods for Motivating Clients

 not
easily answered by yes and no; listen for
appropriate statements and reinforce them while,
initially, actively ignoring cognitive distortions

Affirmation
 affirm
and support any efforts at change; add
compliments and statements of appreciation for
pro-treatment changes; the reinforcement will
increased the likelihood the client will make more
appropriate statements and fewer cognitive
distortions
Support Self-Efficacy
 Support
Roll with Resistance
Methods for Motivating Clients
Deploy Discrepancy (dissonance)
Summarise
good
for examining ambivalence around an
issue; links material; demonstrates careful
listening; prepares client to move on.,

Reflective listening
form
a reasonable guess as to the meaning
of the client’s statement and reflect back;
recognize you may not know what he really
means; reflect emotions as well as words
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2015-04-04
Resistance to change
Some common traps that can cause resistance
Confrontation-Denial
Blaming
 Premature focus
 Labelling
 Question-Answer
 Expert
Not inherent part of our clients
 Observable behaviours
 Fluctuates
 Influenced by therapist’s behaviour
(therapist confronts: resistance goes
up!)
 Resistance is a signal to change
strategy

Responding to resistance
How to overcome resistance
Back off
 Express warmth, empathy, optimism &
genuineness
 Listen, respect and reflect what you
hear
 Emphasise personal control and choice
- and mean it!
 Offer options










Attire & Body Language – appear relaxed
Vocabulary – appropriate intellectual level
Collaboration – with offender, with colleagues
Information – reduces anxiety
Confidence & Reflection - motivates
Face saving ways to change
Patience
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2015-04-04
How to overcome resistance
Behavioural Methods
Accept small steps
 Have an agenda but be flexible
 Give resident some task to do
 Ask for questions
 Allow him to be the expert
 Be responsive: ask for and accept feedback
 Allow resident to feel like they have some
control over process

Stimulus is
Given
Removal of
Stimulus
Behaviour
Increases
Decreases
Positive
Positive
Punishment
Reinforcement
(e.g.,
(e.g., treat)
spanking)
Negative
Negative
Reinforcement Punishment
(e.g., seat belt (e.g., take toy
buzzer)
away)
Punishment
Using punishment
NOTE: punishment will suppress a
behavior but will not eliminate or weaken it.
Therefore, punishment should only be
used to get a very problematic behavior
under control so that treatment may
progress.
 Punishment should only be used with
reinforcement not instead of reinforcement.


To be maximally effective, reinforcers for
the target behavior should be withheld
when the behavior is being punished.
However, when the person is not
engaging in the target behavior, alternate
behaviors should be reinforced.
 If punishment is progressively increased
habituation will hamper its effectiveness.
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2015-04-04
Using reinforcers
Using reinforcement
Reinforce as soon as possible after the
target behaviour has been performed.
 Make it clear what behaviour is being
reinforced
 Level of reinforcement should be
proportional to effort made – avoid
satiation
 Use reinforcement continuously at first,
then intermittently.


Behavioural methods
Positive reinforcement





Link to specific behaviour
Give immediately after behaviour
Tell clients exactly what they did that was
appropriate and why it was appropriate.
Make sure they understand exactly what behaviour
should be repeated and why.
Reinforcement needs to be proportional to the level
of effort that the behaviour took to perform.

Provide patient with opportunities for
success.
 Consider what works as a reinforcer for
each client.
 Reinforce group members when they are
doing well, not just when they are a
problem
 Shaping (reinforcing approximations of desired
behaviour)

Premack principle (hard work now for fun stuff

Extinction (ignoring or redirecting behaviour)
later)
More factors influencing
reinforcement effectiveness
One person’s reinforcer is another person’s
punisher!
 Remember to reinforce group members as
they contribute - not just the group member
who’s exercise is being discussed!

A major gain deserves strong reinforcement. A small gain
deserves a little recognition.
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2015-04-04
What not to reinforce
Negative self statements (“I’m
hopeless…”).
 Vague or benign contributions (unless
shaping).
 General good behaviour (“You’ve all done
very well today”).
 Agreeing with you (“I’m so glad you now
see it my way”).
 Attention seeking

What to reinforce
Initially, approximations of any treatment
goal
 Statements of responsibility.
 Statements of motivation/intention to
change.
 Self esteem, perspective taking, empathy,
concern for others, etc.
 New skills or attitudes.
 Achievement of any other treatment goal

Establishing an effective
therapeutic alliance in the
treatment of sexual offenders
Liam E. Marshall, PhD
Waypoint Centre for Mental Health Care
&
Rockwood Psychological Services
www.waypointcentre.ca
www.rockwoodpsyc.com
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