Overview of Sex Offender Treatment and Treatment for Individuals with DD/ID

The Principles of Effective Correctional Intervention Evidence-based sex offender programs are based on the Risk—Need—Responsivity model (the RNR model). Risk, Need, and Responsivity refer to the undergirding principles of the model.

The Risk Principle The risk principle drives all interventions. Those offenders, who pose a moderately high to high risk to reoffend are identified for treatment. There are indications in the literature that placing low risk offenders in program with high risk offenders can increase the recidivism rates of low risk offenders. The risk principle tell us who we put in programs.

The Need Principle The need principle tells us what we target in treatment programs. Criminogenic risk/need factors are those factors that are most closely associated with the risk to reoffend. Most criminogenic risk/need factors are dynamic factors, i.e., they are stable, enduring factors in an offender’s life that can change.

Criminogenic Risk/Need Factors for Sex Offenders Deviant sexual arousal, interests or preferences Sexual preoccupation Anger and hostility Emotional management difficulties Self-regulation difficulties and/or impulsivity Antisocial attitudes and orientation Antisocial personality pattern Cognitive distortions that support sexually abusive behaviors Intimacy deficits and conflicts in intimate relationships

The Responsivity Principle The responsivity principle tells us how we go about intervening with high risk offenders. The overarching approach is a cognitive- behavioral model that addresses thinking processes, emotional regulation, the skills required for prosocial relationships, and risk management planning (relapse prevention).

The Responsivity Principle As well as the overarching, general model of treatment, the responsivity also addresses specific and individualized issues in an offender’s life. These specific issues impact how treatment is administered. Examples of these issues are learning styles, serious mental illness, cultural issues, and intellectual/development delays.

Clinician Adaptions for DD/ID Clients Use simple vocabulary words Create short sentence Ask one question at a time Wait for an answer before proceeding Confirm that the client understood the question

Thus sex offender treatment for the DD/ID population is based on the RNR model, addressing the specific responsivity factors for this population. Before we look at the specific issues to be addressed with this population, let’s look at an example of an evidenced-based sex offender treatment model.

Structured Treatment Continuum Three Phases Orientation Core Skills Relapse Prevention/Maintenance Sessions

Structured Treatment Curriculum Modules Treatment Readiness Basic CBT Concepts Cognitive Restructuring Emotional Regulation Social Skills Relapse Prevention Maintenance Sessions

Structured Treatment Curriculum Treatment Readiness This module includes sessions to review program rules and expectations, teach the basic skills needed for successful program participation, enhance motivation for treatment, and explore lifestyle factors associated with sexual abuse and criminal behavior. Introduction to Basic CBT Concepts This module includes sessions to introduce the basic components of the relapse prevention plan to be completed in the final module of the program. Participants will also learn about the behavior chain and identify high risk situations.

Structured Treatment Curriculum Cognitive Restructuring This module will include sessions to identify cognitive distortions and explore attitudes/beliefs that support antisocial behavior and sexual offending behavior. Participants will also learn thought stopping and other coping strategies. Emotional Regulation This module will include sessions to target deficits in emotional regulation and impulsivity. Examples include skills for managing urges, reducing anger and hostility, and dealing with rejection and failure.

Structured Treatment Curriculum Social Skills This module includes sessions to teach social skills that address intimacy deficits and conflicts in interpersonal relationships. Problem-solving is also covered in this module. Relapse Prevention Participants will complete relapse prevention plans in the final module of the program and have opportunities for graduated rehearsal of skills. Successful completion of the program requires participants to present their relapse prevention plans.

Structured Treatment Curriculum A structured format for ongoing maintenance sessions are also included for follow-up Booster sessions to review core treatment concepts Graduated rehearsal of self-regulation skills Activities to enhance application and generalization Strategies to engage family and other social support networks.

Specific Risk Areas for Sex Offenders with DD/ID Lack social skills Impulsive Substance Abuse History of delinquency Low self-esteem Poor response to treatment Psychiatric history Sexual Deviance Antisocial Attitudes Susceptible to others influence Phenix and Screenivasan, 2009

Offender Risk History Has this client had official charges or behaviors that could have been prosecuted? Is the client motivated to stay out of trouble or do they have an antisocial attitude? What triggers the client’s behaviors and is the client successfully managing triggers. Is the client aware of the consequences of his/her behaviors? How much disclosure does the client provide about documented behaviors?

Offender Risk History What types of thinking errors are present when discuss the client’s offenses? Any history of violence? Is violence part of the offending? Family roles models—history related to client How does current Behavior Support Strategies address risk? What is in the Individual Support Plan.

DD/ID Clients Lack Understanding of Risk Providers need to educate clients on: Natural Consequences Social Impact Thinking Errors and Replacement

Know Your Client What motivates your client? Does your client realize they he/she has a problem related to risk? What are your client’s blind spots? What are his/her strengths and needs? How can you build off the strengths?

Helping DD/ID Clients See the Reality of Their Situations Questions you might ask: What do you have to lose by continuing your risky behaviors? What do you have to gain by learning socially appropriate behaviors? Are you aware of how you behavior impacts other people?

Cognitive Behavioral Approach with DD/ID Clients Mild to moderate DD/ID clients are concrete and do well with a common language—4 thinking errors. Teach strategies to interrupt and replace negative, repetitive thinking. Give positive options and help promote positive, prosocial thoughts. Focus on social behavior problems which are a result of negative thinking.

Four Thinking Errors 1.Self-centered thinking—it’s all about me. “I do not care if I hurt others as long as I get what I want. 2.Minimizing—reducing the importance of the pain caused; “it’s no big deal”; “I only touched the little girl once. She barely felt it.” 3.Assuming the Worst—catastrophizing; “I made a mistake so you might as well lock me up” 4.Blaming Others—”pointing the finger”; “If staff did their jobs right I would not have to go off on them.”

Treatment Needs Total honesty about all behaviors. Daily feedback on behaviors: Behavior Management System. Little down time: constructive use of time. Relapse Prevention Plan/Monitoring. Safety Plan/Supervision issues.

Addressing Specific Responsivity Issues of DD/ID Clients “The intellectually disabled client with sex offending issues needs assessment instruments and treatment materials adapted to disability issues and needs an approach of consistency and repetition.” Randy Shively

Teaching Key Skills Interpersonal skills Boundaries/internal and external controls/accepting supervision Conflict resolution Intimacy Pro-social behaviors Self-control and behavior regulation Self-confidence Empathy

Considerations for Staff Working with DD/ID Clients Match staff to clients: Some staff are more effective in dealing with higher risk, more aggressive clients. Consider the level of antisocial orientation/antisocial personality pattern. Consider the experience of staff and their backgrounds in terms of training and the knowledge they have acquired.

Considerations for Staff Working with DD/ID Clients Do staff understand the clients’ patterns of behavior, triggers, deceptions, manipulations? Do staff communicate openly and fully with all the team? Do staff have supportive attitudes towards clients? What are approaches to address those who don’t? Are staff consistently supervising clients? James Haaven, 2007

Considerations for Staff Working with DD/ID Clients Have there been any situational changes in the staff? Have there been any apparent changes in how staff have been intervening with clients? Have there been any unique considerations related to risk? Are staff aware of any situations in which clients have access to victims? James Haaven, 2007

Staff View of Risk What do I know about my client’s risk? What triggers my client’s acting out? Where can I safely take my client? And conversely, where can I not take safely take my client? Who is my client not safe to be around? What would I do if the most serious risk issue arises?

Staff View of Risk What do I need to keep in mind in terms of supervision in the community? What do I need to keep in mind in terms of supervision with the client at home? What process/procedure do I follow to report information if the client is not cooperating or does something risky? What makes the client feel safe, and what makes the client feel unsafe?

Do’s and Don’ts of Supervision DO opt for close supervision, then gradually decrease it as the offender consistently demonstrates the ability to choose pro-social behaviors. DON’T underestimate or minimize the risk posed by clients with sexual deviance/sexually assaultive behaviors.

Do’s and Don’ts of Supervision DO hold the client responsible for all of his/her behaviors. DON’T just focus on the behaviors which got the client in trouble. DO allow natural consequences to occur. DON’T get into power struggles with the offender unless community safety is at risk.

Do’s and Don’ts of Supervision DO make residential and vocational placement decisions with a great deal of caution and consideration of the client’s modus operandi and victim selection. DON’T place a client with sexual behavior problems in any setting that stimulates temptation or increases risk, e.g, don’t place a pedophile next to a daycare center.