Treating Dynamic Needs Sex Offenders with Cognitive Impairments & Serious/Persistent Mental Illness Mary Owen, LCSW-R Chief of Service, SLPC – SOTP Jayme Smith, Psy.D. Licensed Psychologist, SLPC -SOTP

Learning Objectives Examine best practice strategies for training individuals with Cognitive Impairment (CI) & Severe & Persistent Mental Illness (SPMI) in order to understand implications for staffing & treatment delivery Integrate knowledge of Dynamic Factors into treatment practices for the CI & SPMI populations

Defining the Population Sexual abusers Moderate to high sexual recidivism risk Cognitive impairment Serious and persistent mental illness

Bridgeview Diagnoses Sexual Disorders 100% Pedophilia 64% Paraphilia (Rape, Sadism…) 36% Borderline Intellect 35% Psychotic Disorders 25% Personality Disorders: Antisocial 45% NOTE: Most common age range: 41-60

COMMON MISCONCEPTIONS ABOUT SPMI AND CI SEX OFFENDERS AND TREATMENT

Facts About SPMI and CI Sex Offenders Sex offenders w/ SPMI constitute about 8% of all men charged in a sex offence SPMI sex offenders are more similar than different from most offenders (Sahota & Chesterman, 1998) Not all SPMI offenders are driven to offend by the illness (Smith, 2000) Individuals with lower IQ’s are less prone to violence in offending (Murray et.al., 1992)

Factors That May Not Be Related To Sexual Recidivism Victim empathy Denial/minimization of sexual offence Lack of motivation for treatment Internalizing psychological problems Anxiety, depression, low self-esteem Sexually abused as a child Low conventional ambition Insufficient fear of official punishment

SEX OFFENDER TREATMENT CLIMATE

Setting the Treatment Climate Traditional approaches to sex offender treatment are NOT effective! Aggressive Confrontational Hostility “Hot Seat”

Setting the Treatment Climate General best practice applies Past separation of SO treatment and traditional therapy techniques and beliefs Therapeutic relationship as a curative factor (Norcoss, J., 2002; Horvath and Symonds, 1991;Frank & Gunderson,1990; Krupnick, et al. 1996) “Improvement in psychotherapy may best be accomplished by learning to improve one’s ability to relate to clients and tailoring that relationship to individual clients.” (Lambert and Barley, 2001) Especially important for SMPI

Setting the Treatment Climate Therapist characteristics influence treatment gains (Marshall, et al., 2002) Empathy Warmth Directive Rewarding Firm but supportive challenging

Setting the Treatment Climate Hopelessness is a huge issue in civil confinement centers Find a realistic goal that keeps hope alive Increased hope is associated with reduced risk for re-offending (Prescott, 2009) Build best context where clients can change (Mann, 2009)

TREATMENT FOUNDATION

COACH vs. KEEPER Focus on individual, not illness People change behavior for things THEY want Change occurs in stages & is tied to trust Positive outcomes can be crafted w/o changing the person Work from a place of respect

FRAMING SO TREATMENT

General Goals of SO Treatment Eliminate sexually assaultive behavior Reduce deviant sexual arousal Reduce criminality Correct distorted thinking Increase adaptive functioning Increase interpersonal skills Increase openness & trust Broaden interests beyond sexuality Educate about healthy sexuality

Treatment Specific to Sex Offenders - Model RNR Model (Andrews, Bonta & Hoge, 1990, 2006) Risk Level of risk considered with level of treatment  Low risk vs. high risk Need Criminogenic Needs Responsivity Tailor treatment to offender  Includes learning style, strengths, weakness, culture

Good Practice Target treatment to the whole person Focus on dynamic risk factors Emphasize dynamic growth Manage symptoms Train to learning styles

ASSESSMENTS TO INFORM TREATMENT

SO Treatment Specific for CI and SPMI - Assessments Assess for psychopathy Sexual deviance combined with psychopathy = increased risk of reoffense (Gretton et al. 2001; Harris et al., 2003) Assess IQ and the parameters of impairment Assess adaptive and social functioning Vineland Adaptive Behavior Scale Can help to determine more about motivations of sexual crime

SO Treatment Specific for CI and SPMI - Assessments Thorough clinical interview Assess severity psychiatric symptoms Clarify how psychosis is tied to sex offense Psychiatric Evaluation PPG

Initial Steps in SO Treatment for CI and SPMI Stabilize psychiatric patients Re-evaluate content of delusions to see if sexual beliefs have become more pro-social Review assessments to develop case conceptualization Basis of treatment planning

Case Conceptualization Gain deeper understanding of why the consumer committed the sexual crime Psychopathy = meeting needs without regard for others Align pro-social goals and self-interest Sexual deviance – sexual orientation towards children Evaluate for appropriate sexual arousal Focus on reconditioning / anti-androgens

Case Conceptualization Psychosis-based sexual beliefs No improvement of delusions while medicated External management Safety planning Poor Social Skills / Developmentally Delayed Focus on sexual education, social skills and safety training ‘Counterfeit deviance’ hypothesis More rare

TREATING DYNAMIC RISK IN OFFENDERS WITH SPMI

Dr. Thornton says…. “The presentation argues that the psychological risk factors which we usually think of as dynamic generally function more like enduring traits so that they change only slowly and with difficulty. However, there is evidence that targeting psychological risk factors related to recidivism is more helpful than targeting other factors and that treatment participants can learn to manage these enduring traits more effectively so that those who manifest them less in environments that challenge the traits go on to show less recidivism than those who continue to manifest them.”

Dynamic Risk Factors Mann, Hanson & Thornton (2008) Sexual Preoccupation Deviant Sexual Interests Offense Supportive Attitudes Emotional Congruence with Children Poor Adult Attachment Lifestyle Impulsivity Resistance to Supervision Poor Problem Solving Grievance Thinking Hostility Negative Social Influences

ADDITIONAL CONSIDERATIONS Self-regulation Social Skills Medication Adherence

Practical Applications Disclosure Autobiography Relapse Prevention Plan

Features of Mental Illness Lack of stable identity Disorganized thinking Vulnerability to stress / Changes in the environment Difficulty solving problems Poor self-care Social withdrawal Abandonment of family responsibilities Work incapacity

Schizophrenia and Cognitive Dysfunction Most common difficulties: Attention Memory Executive functioning Note: those with negative symptoms often have more cognitive difficulty

SPMI & SO Treatment More open about sexuality Increased sexual dysfunction (ED) Increased faulty sexual knowledge (Hughes & Hall, ) SPMI is a disinhibitor – increases criminality, substance abuse, poor social skills, stranger victims (Sahota & Chesterman, 1998)

Factors Associated with SPMI Resiliency Good self esteem Impulse control Adequate social skills Ability to problem solve Good coping skills Ability to delay gratification Ability to manage stress Skill building Social Support

BEST TREATMENT STRATEGIES

Sexual Preoccupation Promote Wellness Management (Self monitoring checklist) Inform on observation of arousal Thought stopping Arousal Reconditioning Consider medications to reduce arousal (SSRI, AAT, Clinician support in psychiatry consults)

Deviant Sexual Interests ID tie-in between delusions & deviance Journaling / charting (adaptive assist PRN – recorder Need vs. want / rational disputing Thought stopping Arousal reconditioning Consider medications to reduce arousal (SSRI, AAT, Clinician support in psychiatry consults)

Offense Supportive Attitudes Group process (Autobiography, Self Disclosure) Cognitive restructuring Confront & supply data Self report to evaluate

Emotional Congruence w/ Children ID perception problems Self perception How others see you Use of video to self assess Could you see…. Environmental structuring Increase adult social / leisure skills

Poor Adult Attachments Develop support network (family, faith, providers…) Whole family education & advocacy Social skills training Appropriate relationships with staff members Increase ability to be intimate

Problem Solving Develop partnership (supportive presence; collaborative problem solving) ID skill for development (model, role play, practice, performance feedback, real life practice)

Grievance Thinking/Hostility Cognitive restructuring Find the emotion driving this Immediate feedback Rating Scale 1 (not upset) – 10 (very upset) Check perception against the group or therapist

Negative Social Influences Observation in treatment setting/community Help structure routines (ID options for activity, provide choices, schedule of daily activities) Case Management Day Treatment/Social Club Formal contingencies SIST ACT Team Kendra’s Law

Self-regulation Impulse Control Training Motivation for Treatment Medication DBT Pointing for Boundaries

COGNITIVE IMPAIRMENT

Static and Dynamic Factors (Lindsay, Elliot & Astell, 2004) Anti-social Attitude Poor Response to Treatment Offenses Involving Physical Violence History of Violence Staff Complacency Deterioration of Family Attitudes Unplanned Discharge Poor Maternal Relationship Low Self Esteem Lack of Assertiveness Attitudes Tolerant of Sexual Crimes Low Treatment Motivation Erratic Attendance and Unexplained Breaks from Routine

Static and Dynamic Factors – Differences The following factors MAY NOT be associated for recidivism in CI population: Employment History Criminal Lifestyle Criminal Companions Diverse Sexual Crimes Victim Choice (Lindsay et al., 2004)

Practical Applications Disclosure *Denial* Autobiography Relapse Prevention Plan

Standards of Care for CI Positive relationship Person-centered care Consistency of services (long term case manager – even when hospitalized) Team-based service Family participation to increase therapeutic reach

Cognitive Impairment (Horton & Frugoli, 2001) Modalities to Use: Psych-Ed (use pictures, art, role play, audio music) Narrative & Storytelling Family Work Skill Building/Practice Individual Work (to increase comprehension and reinforce/homework)

Anti-social Attitude Token economy Align pro-social actions with their goals Emphasize rewards for pro-social behaviors Consistent and immediate consequences for anti-social behaviors

Low Self-Esteem Social skills training Emphasis on positive Skills training Sexual education

Attitudes Tolerant of Sexual Crime Cognitive restructuring Group process Sexual education Model & enforce clear rules / boundaries Set positive expectations Footprints Resource: Footprints

Staff Complacency Do not excuse behavior due to CI Remember that this population can change Clinical staff must be in contact with ward staff to reiterate expectations Hold staff members accountable

Deterioration of Tx Compliance Low Tx Motivation Investigate reasons for this Reassess responsivity needs Wrong treatment modality External motivation for treatment Structure successes Psychiatric consultation

Violence Anger management Root causes Psychiatric consult Reduce stimuli

Deterioration of Family Encourage contact even w/o consent. We can always listen & use good information Ask how they prefer to receive information Ask their perception of the illness, experiences and priorities in care/treatment Assume they’ll be involved long after you are gone Share stories & encourage peer support

Poor Maternal Relationship Family psycho-education on sexual offending Multi-family psycho-education to bring supports into collaborative problem solving

Lack of Assertiveness Establish therapeutic alliance Set goals with the person Behavioral rehearsal Positive reinforcement Shaping & prompting Modeling Homework & practice

Erratic Attendance and Unexplained Breaks from Routine Provide/promote routines, structure and consistency Develop short commands to eliminate impulsive actions “stop” Demonstrate and promote practice of procedures and sequences taken in everyday problem solving situations Offer guiding questions (What's the first step? What do you do next?)

SKILL TECHNIQUES

Important Note Many of the previous interventions are consistent with best practices for treating SPMI & CIs. You are on the right track!

Common Impairments in Cognition or Thinking with Mental Illness Memory Attention-span Ability to focus/Concentration Multitasking  Processing speed Problem solving Language Visual-Spatial/Visual-Motor Processing

Strategies to help memory Repeat information/instructions Present one new concept at a time Ask person to repeat or paraphrase what you have just said Put new information into context (everyday examples)

More Strategies to help Memory Put things in writing/encourage person to write down important information to be remembered Use memory aides: calendars, notebooks/diaries, pill containers, watch alarms, sticky notes

Strategies to help attention Use the person's learning style (auditory or visual) Keep it simple (be direct, short and to the point) Only one task at a time. Make things interesting (use voice, change tone, volume, gesture) Decrease distractions (noises, activity)

More Strategies to help Attention Use direct eye contact and sense of touch can be used once attention is gotten and to sustain involvement Provide a balance of activities across physical, mental and social domains Allow more time to complete tasks

Strategies to help Executive Functioning Provide/promote routines, structure and consistency Develop short commands to eliminate impulsive actions “stop” Demonstrate and promote practice of procedures and sequences taken in everyday problem solving situations Offer guiding questions (What's the first step? What do you do next?)

More Strategies for Executive Functioning Provide frequent encouragement and praise for actions that are initiated, attempted, maintained Give specific feedback regarding behavior (provide an explanation for why the strategy is incorrect and offer alternatives) Use self talk by verbalizing out loud Observe actual performance when assessing skills

Social Skills Training Rehearsals ID & Develop Circles of Support

Techniques for Managing Cognitive Dysfunction Total communication Compensation strategies Adaptive approaches

Setting Low stimulus environment Few Distractions Frequent Rest Breaks Keep group time short or modify 1:1 time

Teaching Approach Structured Instruction Presented in Variety of Formats Focus on: Adaptive Skills Coping Skills Keep Pace Slow Repeat Information Frequently

Strategies to help language Comprehension: Keep things simple, direct, short and to the point Speak concretely not abstractly Try explaining things in a different way

Groups as Experience vs. Lesson Slow processing Clarify before, during, after Don’t use all CAPS in handouts Do you think you may have sexual thoughts about…? STOP drawing if deviant (rehearsal) Arousal – Notice, promote thought stopping

Conduction Group Sessions Start by focusing on a picture What is happening? What is the person doing? Thinking? What will happen next?

IDENTIFY GOALS/PROBLEM AREAS FOR SESSION Anger Management Problem Solving Help clients define problems by asking “what, who, where, when.” 1-2 specific problem areas for session. Examples: Initiating conversation, disagreement with medication, angry at staff behavior. Using free time, telephoning family/others, managing money…

COACHING REHEARSALS When demonstrating “how to say” something while a rehearsal is in progress, use non verbal hand signals: Stop….hand up Slow…..two hands, taffy pull Speed Up…one finger making a circle Smile or look serious….hands at corner of mouth, up or down. Good job…..thumbs up Talk louder, softer…….palms up/down Eye contact…..finger to eye When demonstrating “what to say” during rehearsal, stand close and whisper in client’s ear. Make sure this is OK with the client. Usually the coach’s close proximity to the client during the scene gives support and encouragement.

ASSIGN & CHECK HOMEWORK Make out individual assignment cards. Give clear instructions, keep it simple, give real life assignments. ID any obstacles in carrying out the assignment. Praise success. Document results

IMPLICATIONS FOR STAFFING & TREATMENT DELIVERY

Tools to Support Responsivity Needs Staff training on teaching techniques Targeted modules / Simplified learning packets Multi-modal equipment Smaller processing more rehearsal Need for smaller groups Shared treatment resources

Vicarious Trauma Not so much a question of if, more a question of when Provide clinical supervision and support for therapists System wide