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Self-Care for Professionals Working with People Who Offend Sexually
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Changing Attitudes, Changing Practice
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 • The Key Essential Elements of Contemporary Sex Offender Treatment:
A Brief Summary
 • What Treatment Providers Can Learn From Yoga Instructors
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International Perspectives on the Assessment and Treatment of Sexual Offenders:
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Vol. XXV, No. 3-4
Summer-Fall 2013
The Key Essential Elements of Contemporary Sex Offender Treatment:
A Brief Summary


Introduction

The treatment of sexual offenders has changed dramatically over the years. This is reflected in the history of treatment, which fluctuates depending upon the observer, as reflected in numerous interviews conducted by M. Carich (Carich, Smith, & Cameron, in press; see also Laws & Marshall, 2003; Marshall & Laws, 2003).

Sex offender treatment has been dominated over the last 25 to 30 years by cognitive-behavioral therapy (CBT) with a heavy emphasis on relapse prevention (RP), until recently (Laws, 2003). However, some (e.g., Yates & Ward, 2009) have suggested throwing out RP and replacing it with a combination of the Good Lives Model (GLM) and Self-Regulation Model (SRM). RP has been under scrutiny for a number of reasons (Laws, Hudson & Ward, 2000). Carich, Dobkowski & Delehanty (2009) have suggested integration and balance. Likewise, over the years, treatment targets have also changed (Carich & Adkerson, 1995; Carich & Adkerson, 2003; Carich & Calder, 2003; Carich & Calder, 2012; Carich & Mussack, 2001; Marshall, 1996; Marshall, 1999; Marshall, Anderson & Fernandez, 1999; Marshall, Marshall, Serran & Fernandez, 2006; Marshall, Marshall, Serran & O’Brien, 2011; Metzger & Carich, 1999). Typically, mental health types want to treat everything whether it needs it or not. Paradoxically, most therapy programs do not have the time, resources, or luxury to treat numerous targets. Therefore, given the current state of affairs, the question arises, what are the essential elements of treatment?

In program theory, it is suggested that within a particular program treatment targets are converted into treatment elements and examined for themes (Carich & Calder, 2011). Every program, even if consisting of one group, has a recognized or underscoring program theory. Thus, treatment goals are targeted via treatment elements (Carich & Calder, 2003). The purpose of this paper is to briefly outline what are considered to be the essential elements or themes of contemporary treatment, realizing the field is undergoing a rapid shift.

Mark S. Carich, Ph.D.

Bruce Cameron, M.S.

Heather Young, M.A.

Monica Parkins, M.S.

Theoretical Parameters of Treatment

As mentioned earlier, treatment has evolved over time, starting out psychodynamically, then moving to behavioral treatments, followed by cognitive therapy with an intensive shame-based and confrontational punitive methodology leading to contemporary CBT treatment with a heavy emphasis on RP. The current push is on totally abandoning RP, replacing it with GLM and SRM (Yates & Prescott, 2011; Yates, Prescott & Ward, 2010; Yates & Ward, 2009). Interestingly, and ironically, Adler (1934, 1941, 1956) may have been one of the first to treat paraphilias in modern times and was definitely the forerunner of CBT, group work, family systems, and even the GLM.

The classical CBT model is based on the reciprocal influential relationship between cognitive and behavioral experiential domains. By the late 1980s, RP was attached to CBT, creating a CBT-RP approach. It is interesting that traditional treatment is changing, as all experiential domains are recognized, including the emotional, as Marshall, Marshall, Serran and Fernandez (2006) have added an emotional component to their program approach title, moving beyond CBT, as well as recognizing the importance various theories of GLM (Marshall, Marshall, Serran & O’Brien, 2011). The GLM can easily be integrated into contemporary treatment (Carich, Dobkowski & Cameron, 2012; Ward & Gammon, 2006; Ward, Mann & Gannon, 2007; Yates Prescott & Ward, 2010).

The key connecting theoretical points hinge on self-determinism as people make complex choices to offend, and the theological view that behavior is goal oriented and serves purposes. Within this, people are held accountable for their behavior. However, one’s view of self and change of self plays a role. Part of the integration occurs by adopting a holistic view of self, thus appreciating all the various experiential domains of self and the recognizing the complexities of change (Carich & Dobkowski, 2007; Carich, Dobkowski & Cameron, 2012; Carich, Williamson & Dobkowski, 2008). Social learning theory remains an important theoretical component, as well.

The GLM adds various needs, or what are referred to as primary goods (or goals) that one tries to obtain or fulfill according to life plans (Ward, 2002; Yates, Prescott, & Ward, 2010). These are either fragmented (chaotic) or coherent (stable). As treatment is transformed, at some level, treatment elements or themes need to reflect life plans to some degree via targeting the “right” or key dynamic risk factors (DRFs).

Translating DRFs into Treatment Elements

Dynamic risk factors are those behavioral and lifestyle factors related in some degree to offending. These are issues, targeted dysfunctional behavior problems, criminogenic factors, etc. (Carich, Spilman, & Stanislaus, 2008). These factors can change and are dynamic in nature. Typically, DRFs are translated into treatment goals, which have been addressed in the literature (Carich & Adkerson, 1995; Carich & Adkerson, 2003; Carich & Calder, 2003; Carich & Calder, 2011; Metzger & Carich, 1999). In terms of program theory, we distinguish DRFs, treatment goals, and treatment elements or themes. Targeting DRFs via goals and objectives is reflected in various themes within the program (Carich & Calder, 2011).

 

Common DRFs

There are numerous DRFs, treatment goals or targets, elements and typologies, etc. throughout the literature from over the last 30 years (Beech & Fisher, 2002; Carich & Adkerson, 1995; Carich & Adkerson, 2003; Carich & Calder, 2003; Carich & Calder, 2011; Hanson & Harris, 2001; Marshall, 1996; Marshall, 1999; Marshall et al., 2006; Marshall et al., 2011; Marshall & Serran, 2005; Metzger & Carich, 1999; Mussack & Carich, 2001; Thornton, 2002) summarized by Carich, Spilman & Stanislaus (2008). A brief outline of several are found in the following – Common DRFs:

  1. Hanson & Harris (2001): SONAR/Stable-2000
    1. Intimacy skills/deficits – meaningful relationships, attachments…
    2. Social influences
    3. Attitudes (not in Stable 2007)
    4. Sexual self-regulation skills- preoccupation controls…
    5. General self-regulation skills
    6. Cooperation with supervision
  2. Thornton (2002): SRA
    1. Sexual interest- preoccupation
    2. Socio-affective functioning- loneliness, esteem, passive victim stance, intimacy, aggression, anger, paranoia
    3. Distorted attitudes- entitlement, justifications
    4. Self-management skills- regulation
    5. Criminogenic needs
  3. Marshall (1999): Treatment Targets
    1. Offense specific
      1. Denial/minimization
      2. Distorted perceptions
      3. Victim empathy
      4. Pro-offending attitude
      5. Attachment style
      6. Deviant fantasies
      7. Relapse Prevention
    2. Offense related
      1. Substance abuse
      2. Anger management
      3. Problem-solving
      4. Living Skills
      5. Emotional disorders
      6. Stress management
      7. Sex education
      8. Social skills
      9. Parenting skills
      10. Adult survivors of sexual abuse
      11. Constructive use of leisure time
  4. Marshall (2006): Current Treatment Targets—Offense Specific
    1. Autobiography
    2. Self-esteem
    3. Acceptance of responsibility
      1. Denial/minimizations
        1. Schema (cognitive distortions)
        2. Victim harm
        3. Empathy
    4. Offense pathways
    5. Coping styles/skills
    6. Social skills
      1. Anger
      2. Anxiety
      3. Assertiveness
      4. Intimacy/loneliness
      5. Attachments
    7. Sexual interests
    8. Self-management plans
      1. Avoidance strategies
      2. Good life plans
      3. Warning signs (self & others)
      4. Support groups (professional & personal)
      5. Release plans (work, accommodation, leisure activities)
    9. Substance use/abuse
    10. Anger management
    11. Parenting skills
    12. Cognitive skills (now called reasoning & rehabilitation)
    13. Spiritual issues
    14. Other psychological problems
  5. Beech & Fisher (2002): Four Factors of Treatment
    1. Denial, minimization & justification
    2. Offense specific focus
      1. Dysfunctional thinking patterns
      2. Victim empathy
      3. Deviant sexual arousal
    3. Socio-affective
      1. Self-esteem
      2. Intimacy
      3. Attachment
      4. Assertive skills
      5. Managing emotional states
      6. Problem solving skills
    4. Relapse prevention
      1. Identifying offending precursors
      2. Self-management skills

These areas are thought to be related to offending to varying degrees. Interestingly, some of these DRFs are not supported in the classical meta-analysis conducted by Hansen and colleagues (Hansen & Bussiére, 1996; Hansen & Bussiére, 1998; Hansen & Morton-Bourgon, 2004; Hansen & Morton-Bourgon, 2005). For example, denial and related responsibility, empathy deficits, motivation, relapse prevention skills, social skills, etc. are not strongly (or at all) correlated with sexual recidivism. Yet, there are bodies of literature that indicate deficits in these areas summarized by a variety of authors (beech & Fisher, 2002; Carich & Adkerson, 1998; Carich & Adkerson, 2003; Carich & Calder, 2003; Carich & Calder. 2011; Carich, Spillman & Stanislaus, 2008; Marshall, 1996; Marshall, 1999; Marshall & Eccles, 1991; Marshall et al., 2006; Marshall et al., 2011).

Furthermore, it has been pointed out that these same factors are either defined differently across studies and/or very complicated to define. Some factors dovetail with other factors or can be subcategorized under others (Carich, 1991; Carich, 1997; Carich, 1999; Carich et al., 2008). Interestingly, Hanson (2000) maintained two key risk factors: antisocial personality and deviant sexual interest. More recently, Mann, Hanson, and Thornton (2010) reviewed the literature, focusing on DRFs based on the empirical research. Their findings are found below. The meaningful DRFs are considered key criminogenic treatment targets. Marshall, Marshall, Serran and O’Brien (2011, p.139) have provided a more concise list of criminogenic targets:

  1. Attitudes/cognitions
    1. Adversarial sexual beliefs
      1. Men should dominate/control women
      2. Women are deceitful
      3. Hostile/distorted views of women
      4. Some women deserve to be raped
    2. Child abuse supportive beliefs
      1. See children as sexual beings
      2. Emotional identification with children
    3. Antisocial attitudes
    4. View themselves as low risk to reoffend
    5. Sense of entitlement
  2. Self-regulation issues
    1. Poor behavioral regulation
    2. Poor coping/problem-solving
    3. Emotional dysregulation
  3. Relationship problems
    1. Intimacy deficits
    2. Lack of relationship skills
    3. Maladaptive attachment style
    4. Emotional loneliness
  4. Sexual issues
    1. Poverty of sexual knowledge
    2. Any deviant or paraphilic sexual interest
    3. Sexual entitlement
    4. Sexual preoccupation

Throughout all of the controversies, and with some common sense, there are several categories of DRFs that contain two subfactors.

Summary List of DRFs (Treatment Targets)

  • Cognitive factors (distortions, core schemas, attitudes, etc.) including responsibility
  • Affective functioning/mood states
  • Interpersonal/attachment issues, relationships, skills…
  • Arousal, sexual deviance and/or interest/preoccupation
  • Specific (i.e., pattern) and general self-regulation deficits
  • Victim empathy, social interest related factors
  • Criminogenic needs and/or core causative motivational factors/issues
  • Lifestyle behaviors (impulsivity, etc.)

These categories of DRFs or treatment targets can be refined and translated into treatment goals and objectives. For example, Metzger and Carich (1999) developed a comprehensive 36-page treatment description serving as an effective “master plan” from which additional, user-friendly treatment plans can be developed. Conceptually, treatment targets can be encompassed or viewed in terms of treatment elements.

 

Treatment Elements and Themes

Treatment has been summarized over the years into various treatment targets, elements, and components (Carich & Calder, 2003, 2011; Carich & Mussack, 2001; Marshall, 1990, 1995, 2005; Marshall, Marshall et al., 2006, 2011; Marshall, Anderson & Fernandez, 1999; Schwartz, 1995. Treatment elements are themes of treatment within one’s program theory that reflect what areas exactly are being treated within any particular program, consisting of one group or rather a complex series of groups. These are elements of the intervention that reflect the core components of one’s program or treatment activities. Ten key themes and elements central to sexual offender treatment are presented below:

  1. Offense disclosure/responsibility
  2. Offense specific/related cognitive restructuring
  3. Offense process (pattern)/Intervention (regulation) skills
  4. Change maintenance via pattern identification and intervention
  5. Victim empathy and related prosocial perspective taking
  6. Arousal control or regulation skills
  7. Clinical (core) issue resolution
  8. Social skills, interpersonal issues/relationships
  9. Affect regulation skills
  10. Lifestyle restructuring

However, the question remains, what are the essential elements of sex offender treatment in general? The following is a list of essential elements that can be considered key treatment themes:

  • Responsibility and cognitive restructuring
  • Empathy
    • Victim specific
    • Global
  • Regulation (coping) skills
    • Sexual arousal
    • Mood management
    • General intervention regulation skills
  • Change maintenance strategies (RP related)
    • Offense/dysfunctional patterns/processes and regulation (coping) skills
  • Interpersonal (skills, issues, attachments)
  • Needs and core issues
    • Esteem/worth related issues
    • Related motivational and emotional needs and issues

It is noted that interpersonal skills and attachment issues or relationships will be naturally addressed throughout the group process. Furthermore, high risk clients need to address core needs and motivated core issues. Otherwise, unless time permits, core issues typically are not addressed. It is further noted that motivational core issues may also be targeted if necessary as background risk factors, again, time permitting.  More specifically, a summary list of core treatment elements includes the following: a.) cognitive restructuring and responsibility, b.) empathy (perspective taking), c.) regulatory (coping) skills, including mood and arousal control, d.) change maintenance skills (pattern intervention), e.) motivational core issues, and f.) interpersonal issues and attachments.

These elements matter depending on how treatment services are delivered. Since each client is uniquely different in terms of risk level and needs, the degree to which these elements are addressed will vary as well. In terms of the Good Lives Model, specifically, primary goods (and sometimes secondary goods) are reflected within the treatment elements. These needs or goods are mostly related to the established DRFs.

Treatment Delivery and Risk-Needs-Responsivity (RNR)

Treatment delivery is best conducted with the RNR principles as a driving force (Marshall, Marshall, et al., 2011). The client’s risk levels and needs are matched with treatment dosage and overall elements used. Responsivity refers to the clinician being responsive in matching treatment interventions with the client’s learning style and needs. Treatment is ineffective if the client cannot relate to the clinician and/or process. Thus, a treatment context needs to be considered change-oriented and user-friendly. Many of these dynamics hinge on the therapist style, therapeutic alliance, therapist skill level, etc.

The days of shame-based therapy or treatment are over, as favor has shifted to more positive psychology approaches (Carich & Dobkowski, 2009; Carich, Williamson. & Dobkowski, 2008; Marshall et al., 2006; Marshall et al., 2011; McMurran & Ward, 2004; Prescott, 2009; Yates, Prescott, & Ward, 2010). Treatment delivery hinges on process variables, or variables related to the clinician in delivering treatment processes. There are a number of key process factors that are considered important. This specific topic is somewhat beyond the scope of this article; however, the reader is referred to the following authors for clarification of the research: Carich and Dobkowski (2009), Carich, Williamson and Dobkowski (2008), Marshall et al. (2006), Marshall et al. (2011), Marshall and Serran (2000), and Prescott (2009). However, there are four key factors that need to be addressed.

Four Key Process Factors

From all the tedious research conducted by Bill Marshall and colleagues, several factors paralleling some of Assay and Lambert’s (1992) research on successful psychotherapy remains important. Marshall (2005, 2007 interviewed by Carich and Scott Smith) outlined four key functions that need to be incorporated in any successful sex offender treatment context:

  • Respect and rapport
    • Therapeutic connection at some level with the client
  • Encouragement/Reward (reinforcement) or positive behavior and responses
  • Hope for change or something different
  • Directive to a degree
    • Some level of structure and guidance

 

Conclusion

There are numerous dynamic risk factors (DRFs) that can be targeted in treatment (Carich, Spilman, & Stanislaus, 2008). DRFs can be complex and interrelated with each other, varying in levels of risk correlation to sexual offending behavior. DRFs are translated into treatment targets and/or goals. Treatment targets will vary amongst individuals depending upon any number of factors (e.g., background history, personality characteristics, level of deviant fixation, motivation, program resources, offense pattern processes, etc.). Yet, there seem to be common factors amongst the clientele that vary as well. These factors are translated into, and reflected as, program elements or themes. Questions always arise as to what are the key treatment themes and/or elements? Several were proposed, including:

  • Cognitive restructuring
  • Empathy
  • Change maintenance
  • Emotional regulation skills

It was suggested that attachment and interpersonal skills will naturally be addressed within the group process. It would appear from clinical experience that this summary applies primarily to those in low to moderate risk groups. The very high risk groups usually found in civil commitment programs are typically clients with chronic, fixated, sexually deviant patterns, and dysfunctional personality characteristics—most with complex trauma histories requiring even more additional work.

The last thing addressed was treatment delivery. Treatment delivery is based on the process variables (Marshall, 2005). The summary of essential elements will be reflected by the Risk-Need-Responsivity principles as applied to the client. A clinician can target all the right DRFs and have all the right treatment elements; however, the outcome hinges on treatment delivery. Ineffective treatment delivery usually yields ineffective results. Effective treatment delivery involves the use process variables alluded to by Marshall (2005) and Marshall, Marshall, Serran, and O’Brien (2011). The use of process variables is included in positive psychology, and the current push in the field is integrating positive psychology. However, with the integration of positive psychology via the Good Lives Model (GLM), the field is moving beyond basic CBT towards a Cognitive-Behavioral Dynamics therapy incorporating a holistic view. This appears to be the future of the field.


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