1	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
2	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
3	Two Facets of Sex Offender Management: Addressing both External and Internal Controls
4	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)
5	What Methods are Effective? Cognitive-behavioral techniques Adult learning theory methods Positive reinforcement rather than punishment Respectful confrontation
6	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
7	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
8	Monitoring and Quality Control of Treatment are a Must Monitoring of: Program activities Clients
9	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
10	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
11	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)
12	Methods to Address Cognitive Distortions Role-play explaining to a victim all the information he would need to give “informed consent” to sexual activity
13	Methods to Address Cognitive Distortions (cont.) Articulating the thinking errors and cognitive distortions offenders use to excuse their behavior
14	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
15	Methods to Address Victimization Awareness Videotaped programs of sexual assault victims Visits by victims to the treatment group
16	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”
17	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
18	The Four Domains of Treatment Sexual Interests Distorted Attitudes Interpersonal Functioning Behavior Management
19	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
20	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
21	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
22	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
23	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
24	Common Questions Can offenders sabotage this? Who is this best suited for? Is this technique essential? Can this technique be used exclusive of others? Yes—but they’re only hurting themselves Offenders with significant deviant sexual arousal No—but some intervention must address deviant sexual arousal No
25	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”
26	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
27	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
28	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%
29	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%
30	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
31	Methods of Administration and Costs: Antiandrogens Depo-Provera Injected weekly $40 per week Provera Administered orally Depo-Lupron Injected monthly $400 per month
32	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
33	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
34	Cognitive Restructuring 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
35	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
36	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
37	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
38	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
39	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
40	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
41	The Goals of Increasing Interpersonal Functioning 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
42	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
43	Methods of Social Skills Training Presentations on relevant topics Role playing various types of social settings Behavioral assignments with reports back to the group
44	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
45	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
46	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
47	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
48	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
49	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
50	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
51	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
52	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
53	Relapse Prevention Cycle
54	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
55	Goals of Relapse Prevention (cont.) 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
56	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
57	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
58	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
59	Methods of Relapse Prevention (cont.) Teach relapse rehearsal Promote lifestyle changes Identify pro-social methods to express power
60	Adjunctive Therapies Marital and family therapy Family education seminars and couples’ groups Substance abuse treatment Educational/vocational supports Individual therapy (usually for other issues)
61	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 www.atsa.com
62	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
63	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
64	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
65	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