Some Organising principles for the treatment of sexual offending

Dr Adam Carter Trent Study DayJuly 2013

Presentation outline Consider the contents of contemporary treatment

programmes for tertiary prevention Look at extent treatment programmes confirm to

evidence-based principles Speculations on discrepancy between evidence

and practice Outline a proposed model of change and expand

on organising principles that could underline treatment

Conclude how the overall framework may develop new generation of treatment programmes

Key references Mann, R.E. & Carter, A. J. (2012). Organising

principles for the treatment of sexual offending. In B. Wischka, W. Pecher & H. van der Boogaart (Eds)., Behandlung von Straftätern: Sozialtherapie, Maßregelvollzug, Sicherungsverwahrung [Offender treatment: Social Therapy, Special Forensic Hospitals, and Indeterminate Imprisonment]. Centaurus.

A Bio-psycho-social theory of sexual offending, Mann & Carter, in preparation.

Ideas formed over 2 years during design of new suite of treatment programmes in NOMS with people working in the field

Current treatment approaches

‘What works’ literature - benefits to adopting a treatment approach (McGuire, 2002)

Meta-analysis of treatment programmes show small but overall effect of treatment (Lösel & Schmucker, 2005)

Treatment of sexual offending remains one of the more controversial corners of offender rehabilitation

Current treatment approaches cont.

Principles of risk, need and responsivity constitute the most strongly evidenced approach to reducing recidivism (Andrews & Bonta, 2006)

Risk Needs Responsivity model - applicable to treatment of sexual offending (Hanson, Bourgon, Helmus & Hodgson, 2009)

Absence of commitment to these principles – sometimes GLM favoured instead

However – GLM and RNR should be seen as complimentary

Many programmes not compatible with RNR either

Criminogenic needs

Sexual preoccupation

Any deviant sexual interest

Offence supportive attitudes

Emotional congruence with children

Lack of intimacy Lifestyle impulsivity Poor cognitive

problem solving Resistance to rules Grievance & hostility Negative social

influences

(Mann, Hanson & Thornton, 2010)

Protective factors

Healthy sexuality Constructive

occupation (including employment)

Motivation to desist Hope Agency Positive identity

An intimate relationship

Healthy social support (a place within a group)

Sobriety Being believed in

(Maruna, 2010)

Current practice (US) >80% programmes (McGrath et al, 2010)

Offense responsibility

Victim empathy

Intimacy skills

Social skills

Not criminogenic

Not criminogenic

Criminogenic

Not criminogenic

Current practice (Canada)>80% of programs

Intimacy skills

Victim empathy

Emotional regulation

Criminogenic

Not criminogenic

Criminogenic

Current practice (England/Wales prison)

Attitude reconstruction

Victim empathy Self regulation

(emotional regulation, intimacy, problem-solving)

Weakly criminogenic

Not criminogenic Criminogenic

Not doing enough of…?

Sexual self regulation

Sexual interests Offence supportive

attitudes Impulsivity Problem solving &

coping

Grievance, hostility and callousness

Social support Intimacy support Employment or

constructive use of time

Doing too much of…?

Offense responsibility Victim empathy Social skills

Accepting Responsibility

Often assumed to be equivalent to making a full confession

Need for a confession may be intuitive or emotional rather than rational

Failure to confess = refusal to accept sexual offender identity? May be associated with desistance

An alternative to confession-oriented treatment

Focus on taking responsibility for the future

More prevalent in desisting offenders (Maruna, 2012)

(Ware & Mann, 2012)

Organising principles and models of change

Treatment design - begin by developing a “model of change”

CSAAP defined model of change as an explicit and evidence-based model Explain how the programme is intended to

bring about change in offenders Which combination of targets and methods is

likely to work with the offenders selected Murphy et al., recommend identifying

mediators of change Necessary to formulate hypotheses about the

likely mechanisms underlying the action of the treatment

Models of change

Theories of sexual offending that incorporate insights from neurobiological, psychological and criminological traditions (Marshal & Barbaree, 1990; Ward & Beech, 2005)

Explicitly articulate model of change necessary to reduce influence of informal rules

Also necessary to ensure wider literature on why people become vulnerable to offending is considered

Bio-psycho-social models of health and intervention (Engel, 1977) attempt to understand “the interaction between evolved brains, social contexts and experienced selves” (Gilbert, 2002)

Proposed model of change

A brief bio-psycho-social explanation of the empirically-based risk factors that sexual offender treatment should seek to address

- drawing on previous integrated theories

- fast growing biological literature Formal organising principles

Proposed model of change

Treatment exercises should connect to

(a) the psychological risk factors they target

(b) the biological, psychological or social resources designed to build

(c) the organising principles they draw on

Example – Grievance thinking

Bio - mindfulness techniques that enhance acceptance

Psycho – Understand when grievance and rumination have caused problems, challenge this thinking and develop self talk and benefits of managing this thinking

Social – people who will support a less hostile view of world. Work at trust, being accepting and accepting of other people’s views.

Organising Principle 1:

Treatment delivered in a way that is proportionate to the risk of each participant

Low risk - little if any Medium - highly responsive with

dose of about 160 hours (Friendship, Mann & Beech, 2003).

Higher risk - probably significantly greater resources

Organising Principle 2:

Treatment delivered in a way that makes it accessible and appealing whatever their bio-psycho-social circumstances

recognises variety of bio-psycho—social circumstances

can impact on ability to engage and regulate behaviour in therapy

Childhood adversity and the brain – impact upon engagement?

Amygdala - if heightened - hyper vigilant - not in right state to learn

Hippocampus - under development linked to problems with learning and memory

Corpus callosum - difficulty generalising emotions due to compartmentalisation (Creeden, 2010)

Prefrontal cortex-problems with this linked to impulsivity and aggression (Fishbein, 2003)

The biologically informed facilitator.

Show flexibility in targeting treatment needs to enhance engagement and learning e.g. address attachment style problems/mistrustful schemas early in treatment to help with therapeutic alliances

Be responsive to learning style including potential biological vulnerabilities – visual, auditory and kinaesthetic using a range of treatment modalities and accommodate learning styles

Organising Principle 2 cont:

address attachment issues early techniques to favour problem

solving other approaches than

introspection, discussion, and reflection

goals of treatment should be rewarding

Organising Principle 3:

In addressing criminogenic need, treatment should strengthen biological resources

problem solving training mindfulness training monitoring and repetition medication (SSRIs and anti-

androgens).

Organising Principle 4:

In addressing criminogenic need will strengthen psychological resources

Content - where exercises and therapeutic interactions provide repeated healthy forms of psychological functioning

Process - simultaneously generate relevant emotions and cognitive activation allowing learning at the schema level

Organising Principle 4 cont: Pfafflin et al. (2005) application of Mergenthaler’s

(1996) Therapeutic Cycle Model developed in relation to psychotherapy

Identified two change agents within psychotherapy – emotion and abstraction - with four different patterns by which agents can be combined

The connecting pattern - patient expresses his feelings while simultaneously experiencing an understanding of the issue – predicted as optimal for change

Session with greatest occurrence of Connecting rated as being highest quality

Organising Principle 5:

Treatment will strengthen social resources such as social capital

pro social support can help individuals sustain pursuit of primary goals (Ward & Mann, 2004)

Citizenship Social capital treatment should encourage the

development of real social support networks

Organising Principle 6:

Treatment should strengthen intention to desist from offending

motivational interviewing strengthen protective factors positive identity

Promising research

Oxytocin – involved in social recognition and bonding and appears to cause us to form and sustain relationships with othersPaul Zak, Director of The Centre of

Neuroeconomics

There was a partial reverse of atrophy linked to Chronic Fatigue Sydromede Lange et al. (2008)

Presentation conclusions

Extent treatment programmes can reduce sexual recidivism and ability to demonstrate change will continue to be debated

Principles of risk, need and responsivity provide the most evidence-based foundation

Details of these principles need to be better articulated Scope of targets in the engagement and treatment of

sexual offending should be expanded Consideration and debate around organizing principles of

treatment can only improve evidence-based practice

Thank you

adam.carter@noms.gsi.gov.uk