1. Some Organising principles for the treatment of sexual offending Dr Adam Carter Trent Study Day July 2013

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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)

8. Current practice (US) >80% programmes (McGrath et al, 2010)  Offense responsibility  Victim empathy  Intimacy skills  Social skills  Not criminogenic  Criminogenic  Not criminogenic

9. Current practice (Canada) >80% of programs  Intimacy skills  Victim empathy  Emotional regulation  Criminogenic  Not criminogenic  Criminogenic

10. Current practice (England/Wales prison)  Attitude reconstruction  Victim empathy  Self regulation (emotional regulation, intimacy, problem- solving)  Weakly criminogenic  Not criminogenic  Criminogenic

11. 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

12. Doing too much of…?  Offense responsibility  Victim empathy  Social skills

13. 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

14. An alternative to confession-oriented treatment  Focus on taking responsibility for the future  More prevalent in desisting offenders (Maruna, 2012) (Ware & Mann, 2012)

15. 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

16. 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)

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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).

26. 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

27. 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

28. 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

29. Organising Principle 6: Treatment should strengthen intention to desist from offending  motivational interviewing  strengthen protective factors  positive identity

30. Promising research  Oxytocin – involved in social recognition and bonding and appears to cause us to form and sustain relationships with others Paul Zak, Director of The Centre of Neuroeconomics  There was a partial reverse of atrophy linked to Chronic Fatigue Sydrome de Lange et al. (2008)

31. 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

32. Thank you adam.carter@noms.gsi.gov.uk