Elements of Sex Offender-Specific Treatment: Learning Objectives

Elements of Sex Offender-Specific Treatment: Learning Objectives
Describe the components of sex offender-specific treatment Explain why treating sex offenders who deny is important, and describe one method for encouraging sex offenders to admit Identify the four domains of treatment CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Learning Objectives (cont.)
Describe a number of sex offender-specific treatment methods Summarize research findings related to the length of sex offender treatment and therapist style variables Identify several ethical issues in the treatment of sex offenders CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Two Facets of Sex Offender Management: Addressing both External and Internal Controls
The Four Domains of Treatment: Sexual Interests Distorted Attitudes Interpersonal Functioning Behavior Management External Controls: Probation/Parole Supervision Polygraph Testing Registration/ Notification Use of Community Networks External Controls Internal Controls CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Characteristics of Sex Offender-Specific Treatment
Explicit, empirically-based model of change Expected to reduce recidivism Social learning theory-based Addresses criminogenic needs Targets factors closely linked to sex offending (criminogenic needs) CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

What Methods are Effective?
Cognitive-behavioral techniques Adult learning theory methods Positive reinforcement rather than punishment Respectful confrontation CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Treatment is Skills Oriented
Skills to avoid sex offending Skills to engage in legitimate activities “Skills oriented treatment” includes: Defining the skill Identifying the usefulness of the skill Modeling the skill Practicing the skill Giving feedback Practicing the skill again CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

How Long Should Sex Offender Treatment Last?
Until recently, answers to this question were based only on opinion—there is now research that addresses this question Different offenders require different lengths of treatment Higher levels of denial, sexual deviancy, and risk require longer, more intense treatment CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Monitoring and Quality Control of Treatment are a Must
Monitoring of: Program activities Clients CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Treatment of the Denying Sex Offender
Denial is common among sex offenders But, admitting is vital to treatment Sex offenders who do not admit at some point can’t be treated Therefore, treatment of denial is usually necessary to make a client ready for sex offender treatment CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Tools for Addressing Denial
The polygraph—aimed at specific deceptions Physiological indications of deception Offenders often abandon denial Group treatment—targets two issues Eliminating cognitive distortions Developing victim awareness CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Treating Denial Focuses on its Complexity
Many purposes—why offenders are often in denial Multiple pressures to deny Denial in various phases of the offense (before, during, and after) CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods to Address Cognitive Distortions
Role-play explaining to a victim all the information he would need to give “informed consent” to sexual activity CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods to Address Cognitive Distortions (cont.)
Articulating the thinking errors and cognitive distortions offenders use to excuse their behavior CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Increasing Victimization Awareness
If sex offenders come to understand the harm they cause, they will be more reluctant to commit future sex offenses because they will find it more difficult to disregard the consequences of their actions to their victims and others CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods to Address Victimization Awareness
Videotaped programs of sexual assault victims Visits by victims to the treatment group CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Involving Sex Offenders Formerly in Denial
Often graduates of the “deniers’ group” Emphasis on the positive benefits of abandoning denial “If I can do it, so can you” CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

The Culmination of Denier’s Treatment
The denier is at last permitted to discuss his own offense—many are now quite willing to do so Some therapists report that 80% of deniers admit to the offense when this approach is used CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

The Four Domains of Treatment
Sexual Interests Distorted Attitudes Interpersonal Functioning Behavior Management CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Sex Offender Treatment Goals and Plans
Accepting personal responsibility for a complete sexual assault history Improving social, relationship, and assertiveness skills Appropriately managing anger Learning about the traumatic effects of victimization and developing empathy Learning to separate anger and power from sexual behavior Developing pro-social support networks CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Sex Offender Treatment Goals and Plans (cont.)
Recognizing and changing cognitive distortions Identifying and modifying sexual arousal patterns as appropriate via Behavioral interventions and/or Medication Developing and using interventions to interrupt the offense cycle Adopting non-exploitative, responsible lifestyle CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Sexual Interests—The First Domain of Treatment
Deviant sexual arousal is sexual arousal to: Non-consenting partners Non-age-appropriate partners Acts that are abusive in nature For many sex offenders, the primary reason they commit sexual assaults is because they have deviant sexual arousal CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

For Offenders with Deviant Sexual Arousal
If such arousal can be decreased, the likelihood of future sex offending will be decreased Treatment goals include: Reduce deviant sexual arousal while increasing non-deviant sexual arousal Increase reactions to the offender’s deviant behavior as non-offenders react—with disinterest or revulsion CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Behavioral Intervention to Reduce Deviant Sexual Arousal
Based on the idea that deviant sexual arousal is “learned” behavior and can be unlearned Substitutes non-deviant thoughts for deviant thoughts Connects deviant thoughts with non-arousal CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Common Questions Yes—but they’re only hurting themselves
Offenders with significant deviant sexual arousal No—but some intervention must address deviant sexual arousal No Can offenders sabotage this? Who is this best suited for? Is this technique essential? Can this technique be used exclusive of others? CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Pharmacological Interventions to Address Deviant Sexual Arousal
There are two primary types of medications used in the treatment of sex offenders: Selective Serotonin Reuptake Inhibitors (SSRIs) Antiandrogens—used for what some call “chemical castration” CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Selective Serotonin Reuptake Inhibitors
Commonly prescribed for depression Reduce libido (sexual interest) They can also reduce aggression, decrease deviant fantasies, empower people to better manage their behavior, and reduce the intensity of compulsive aspects of sexual offending Many physicians are knowledgeable of and comfortable with prescribing such medications CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Antiandrogen Medications
Drastically reduce testosterone Reduce sex drive and the ability to have an erection “Sexual appetite suppressants” Examples include Provera and Lupron Doctors reluctant to prescribe CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Incidence of Side Effects of Antiandrogen Medications
Decreased sperm count—100% Increased body temperature—100% Decreased sex drive—95% Erectile dysfunction—95% Decreased amount of ejaculate—95% Weight gain—58% Increased blood pressure—50% Fatigue—30% CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Side Effects of Antiandrogen Medications (cont.)
Nervousness and/or depression—30% Hot/cold flashes—29% Headaches—20% Nausea—14% Gall bladder disease (sometimes necessitating surgery)—13% Diabetes—4% Phlebitis (can lead to life-threatening pulmonary emboli)—2% CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Some Physicians are Reluctant to Prescribe Antiandrogens
They are not approved by the FDA for the treatment of sex offenders It is outside of normal, clinical practice to prescribe to men for reduction in sexual arousal CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods of Administration and Costs: Antiandrogens
Depo-Provera Injected weekly $40 per week Provera Administered orally Depo-Lupron Injected monthly $400 per month CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Is Medication Alone an Effective Treatment Method?
Medication that complements the cognitive-behavioral center of treatment can be very helpful in facilitating treatment—5 to 30% can benefit If our goal is to reduce recidivism, and medication will help maintain an individual long enough to help him assimilate the cognitive-behavioral response, it is irresponsible not to use it Conversely, given the current body of evidence, it would be irresponsible to only medicate and not include a cognitive-behavioral treatment component CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Distorted Attitudes—The Second Domain of Treatment
Purpose—to identify and alter offenders’ justifications for sex offending One approach is through cognitive restructuring By examining and exposing these thoughts, justifications, rationalizations, and excuses, the offender is challenged to understand his faulty thinking and recognize its distorted, self-serving nature CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Cognitive Restructuring
Assists offenders to: Examine rationalizations, excuses, and cognitive distortions Obtain candid feedback on these distortions from others Heighten awareness of victimization issues Recognize the faultiness of his thinking Reduce his ability to justify future offending CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods of Cognitive Restructuring
Examine role of distortions in non-sexual situations Offenders anonymously relate the distortions they have used in the past Role-playing of victim, victim’s parent, long-time friend of offender, probation/parole agent Debrief role plays CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Rationale for Victimization Awareness/Empathy Training
Most offenders victimize for selfish gratification If sex offenders learn about the true consequences of their actions for victims, this decreases their ability to discount the trauma that their actions create Most sex offenders have not learned empathy If they learn, they will be less able to ignore the trauma their victims suffer CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Goals of Victimization Awareness/Empathy Training
To understand the pervasive negative effects of sexual assault on victims and others To know the likely consequences of his assaults on his victims and families To learn empathy skills, especially the ability to empathize with his victims CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods of Victimization Awareness/Empathy Training
Presentation of information on the typical trauma to sexual assault victims Use of audiovisual materials Written assignments Group education and confrontation by adult sexual assault survivors CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods of Victimization Awareness/Empathy Training (cont.)
Each offender describes his worst offense from the victim’s perspective Introduces his victim by first name and age Describes how he accessed and groomed the victim Describes what he did to influence the victim not to report Discusses how the victim is doing now Postulates what the victim would like to say to him or ask him now CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Interpersonal Functioning—The Third Domain of Treatment
Why is this important? Persons with poor social skills may, out of frustration: Overpower victims, or Retreat to the lower stress environment of children Improved social skills can reduce the need to resort to abusive behavior to interact with others CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

The Goals of Increasing Interpersonal Functioning
To increase social skills in: Meeting strangers Initiating and maintaining conversations Correctly interpreting non-verbal communication Developing appropriate non-verbal skills Understanding appropriate methods of indicating interest and disinterest Managing anxiety CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

The Goals of Increasing Interpersonal Functioning (cont.)
Appropriate personal disclosure Transitioning from social to social-sexual interactions Maintaining friendships Respecting women and children Understanding the importance of addressing attention to others beyond one’s self CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods of Social Skills Training
Presentations on relevant topics Role playing various types of social settings Behavioral assignments with reports back to the group CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Rationale for Assertiveness Training
Assertiveness increases self-esteem, reduces guilt and anger, and increases satisfaction in interpersonal interactions Sex offenders often suffer from low self-esteem, guilt, and anger when they assert themselves They often store up slights, humiliations, and react with inappropriate anger—sometimes contributing to violent sexual abuse CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Goals of Assertiveness Training
Learn that the primary purpose of assertiveness is not to change others’ behavior but rather to increase self-respect Reduce fear, shame, anger, and guilt in interpersonal interactions Increase self-respect and self-esteem Improve effective interpersonal interactions Teach specific assertiveness skills CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Rationale for Sexual Values Clarification Training
Many sex offenders have deficits in sexual knowledge They may commit offenses in part because they have unreasonable expectations of their sexual functioning, have high anxiety in sexual situations, or have had negative experiences with consenting sexual partners CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Goals of Sexual Values Clarification Training
Increase knowledge about basic, healthy sexual functioning Promote positive, respectful attitudes toward women and children Educate about normal sexual attitudes, behavior, and performance Reduce anxiety about sexual matters Increase information about sexually transmitted diseases CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Behavior Management—The Fourth Domain of Treatment
Sex offending is, by definition, mismanagement of behavior by the offender. Thus, the purpose of intervening in this treatment domain is to assist offenders to manage their behavior in responsible and non-victimizing ways. We will discuss two methods: Covert Sensitization Relapse Prevention CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Goals of Covert Sensitization
To reduce the attractiveness of sexual assault by having the offender focus on the negative social consequences he faces To have offenders explore all of the consequences of their actions—in particular the negative consequences which offenders so often refuse to recognize CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods of Covert Sensitization
Offenders identify the chain of thoughts that lead them to offense behavior Offenders are taught to deliberately interject vivid scenes of the negative consequences they will face during that chain of thoughts Autiotaped homework provides structured practice sessions for this technique that can be reviewed by the treatment provider CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Relapse Prevention First used in the treatment of alcohol and other drug abuse If behavior could be managed to avoid certain situations, then relapse was less likely Applied now in the treatment of sex offenders CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Rationale for Relapse Prevention
Sex offenders who believe that treatment will eliminate their risk for reoffense are more likely to recidivate Offenders who understand that they are never “cured,” recognize offense precursors, and avoid high risk thoughts, feelings, and behaviors are more likely to remain offense-free CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Relapse Prevention Cycle
CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Goals of Relapse Prevention
The sex offender must learn: That prevention of new offenses is a life-long process That certain situations, thoughts, or chains of events pose high risk for reoffense That seemingly unimportant decisions can lead to reoffense CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Goals of Relapse Prevention (cont.)
The sex offender must learn the typical sequence of events that lead to relapse: Perception of control Introduction of a negative mood state Engaging in fantasies of reoffending Development of a plan to commit the offense (Often) use of disinhibiting substance RELAPSE CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Goals of Relapse Prevention (cont.)
The sex offender must learn that: If he interrupts this sequence with positive coping, he can avoid reoffending A lapse is the occurrence of any step in the sequence short of reoffending Interrupting the pre-offense behavior cycle is easiest to do in its early stages CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods of Relapse Prevention
Dispel offenders’ misconceptions about their reoffense risk—IT’S STILL THERE Assess high risk situations Evaluate coping skills and strategies Design intervention plan to avoid first lapse and how to prevent a lapse from becoming a relapse Learn self-monitoring of moods and behaviors CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods of Relapse Prevention (cont.)
Write an autobiography to understand life patterns that result in offending Teach problem-focused coping responses Control stimuli that might promote relapse Teach the relapse process Teach that urges subside with time Teach avoidance strategies CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Methods of Relapse Prevention (cont.)
Teach relapse rehearsal Promote lifestyle changes Identify pro-social methods to express power CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Adjunctive Therapies Marital and family therapy
Family education seminars and couples’ groups Substance abuse treatment Educational/vocational supports Individual therapy (usually for other issues) CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Ethical Practice Standards
Balancing the safety of the community with the offender’s privacy Informed consent Association for the Treatment of Sexual Abusers (ATSA) is the major professional organization that speaks to ethical practice standards in this field ATSA has issued a “Code of Ethics” as well as practice standards and guidelines CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

A Major Ethical Issue: Informed Consent
At a minimum, sex offenders entering treatment should have spelled out to them—preferably in writing: The purpose and nature of treatment Its expected duration Its anticipated benefits, costs, and risks Limitations of confidentiality CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Treatment Provider Characteristics
In the past, sex offender treatment has often involved a punitive treatment style characterized by aggressive verbal confrontation between offender and therapist Several studies examine how therapist styles affect the success of treatment CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Treatment Provider Characteristics (cont.)
Three treatment targets seem to be better achieved with the use of treatment delivered in a warm, empathic, genuine style Reduction of mistrust of women Reduction in sense of entitlement to sexual gratification Reduction in impulsivity CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

Summary We’ve reviewed sex offender treatment
History, current practices, most effective methods, particular techniques and style, and length of treatment The four domains of sex offender-specific treatment: Sexual Interests Distorted Attitudes Interpersonal Functioning Behavior Management Your heightened understanding of sex offender-specific treatment will enable you to work more effectively and collaboratively with treatment providers CSOM Training Curriculum: An Overview of Sex Offender Treatment for a Non-Clinical Audience Long Version: Section 3

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Elements of Sex Offender-Specific Treatment: Learning Objectives

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