|The Role of Human Caring and Compassion in Sex Offender Treatment|
|Joseph Giovannoni DNP, MA, MS, PMHCNS-BC, APRN-Rx |
I am a forensic advance practice
nurse with my own private practice. I
specialize in the treatment of convicted sexual offenders who have been
court-ordered to undergo evidence-based treatment. This essay is a reflection of over 35 years
working with these clients. More specifically, it is about my discovery that,
without human caring and compassion for the men I work with, good outcomes are
less likely. It is about my struggle to
maintain my own sense of humanity and compassion toward sexually violent men. It is about the challenges I have faced trying
to convince others on the treatment team that this approach gives our clients a
better chance of developing their own sense of compassion. My treatment methodology is based on
empirically validated best practices such as cognitive behavioral groups
(Marshall & Laws, 2003). Concern for
others has been identified in sex offender risk assessment as an important need
to be attended to in treatment (Hanson & Harris, 2000). I spend a good deal of time helping my
clients develop concern for others, which begins with my being a role model of
compassion and human caring. My approach
requires being clear about my intentions, and developing self-care to manage
the stress and possible burnout from working with this challenging population. Embodying loving-kindness and compassion toward
self prevents stress and burnout (Giovannoni, McCoy, Mays, & Watson, 2015). In my practice as
a forensic nurse, I have integrated the nursing theory of Dr. Jean Watson (2008). It is ironic that in the health sciences
education and practices, it requires so much knowledge and skills to do the
work, “but very little effort is directed towards developing how to be while
doing the real work on the job.” (Watson, 2008, p. 47) Dr. Watson refers to “be” as being caring and
compassionate regardless of whom that patient/client is. Nurses and other health science professionals
can always become stressed and worn down as they care for others without
attending to their own self-care. The
first process in this human caring theory of nursing is “cultivating the
practice of loving-kindness and equanimity towards self and others.” (Watson,
2008, p. 47) Practicing self-care and
loving-kindness towards self is essential in order to bring calm, soothing, and
compassionate tones to the treatment field as we work with pain and suffering,
and difficult and challenging populations.
Working with a challenging
I have found that the best way to
enhance community safety is to enlist the skills and wisdom of an interdisciplinary
team of professionals. I call these
workers Society’s Safe-Keepers© (SSK). Health
science professionals who engage in sex offender treatment must be able to
exemplify compassion in order to create a safe place for clients to discuss
very sensitive, intimate, and deeply shameful things.
The majority of my clients also
have co-morbidities such alcohol and drug dependence or a mental health
disorder, and may also perpetrate other types of violence. Most of my clients enter treatment exhibiting
antisocial and manipulative behavior. Initially, they rarely admit to their offenses,
they do not take responsibility for their behavior, they are angry and
mistrustful, and some exhibit an aggressive posture toward me and other workers.
theory guided practice as Society’s Safe Keeper
Sex offender treatment is based on
an accumulation of theory and research, such as meta-analyses of predictors of
sex offenders’ recidivism (Hanson & Morton-Bourgon, 2005). Notwithstanding the role of treatment targets,
the importance of therapist style and approach has been found to be critical to
treatment success (Harris & Hanson, 2010; Serran, Fernandez, Marshall,
& Mann, 2003), particularly with respect to retention and engagement. We know now those offenders who do not
complete treatment are at an increased risk of reoffending (Olver, Stockdale,
& Wormith, 2011). Therefore, motivating
this population to stay in treatment, has been shown to be achievable and
related to reductions in recidivism (Marshall, Marshall, Fernandez, Malcolm,
& Moulden, 2008). Approaches such as
motivational interviewing have been helpful with engaging probationers in case-planning
(Miller & Rollnick, 2002). However,
for this approach to be effective, clinicians or SSK need to be authentic, especially
when the client is disgruntled, uncooperative, or resistant to change.
In the face of clients who may be resistant
or disengaged, maintaining a therapeutic approach as described above can be
challenging. There are times when I feel
a burden, especially when I have to make recommendations that also affect my
client’s family members. I have found
myself engaging in self-critical thinking, and have experienced a sense of
helplessness. Dealing with anger, blame,
lack of empathy, and high-risk behavior is arduous. The potential for angry confrontations is
always present. I need to be vigilant to
the potential to become emotionally detached, mechanical, and cynical.
or secondary trauma – dynamics underlying my experience
I am not immune to feelings of
anger and frustration with my clients. It
is easy to justify these feelings when clients have shown no concern and
continue to blame their victims. Years of working with this population and not
paying close attention to my own well being left me on the verge of burnout. We are in the helping profession because we
care and want to help others. But this
trait also makes us vulnerable to experience compassion fatigue or vicarious trauma
when confronted with the impact of sexual violence (Elias & Haj-Yahia,
2016; Ennis & Horne, 2003; Hatcher & Noakes, 2010).
We need to be mindful that being
exposed to people who are suffering can have negative emotional, physical, and
psychological effects on our wellbeing (Perlman & Saakvitne, 1995). Angry clients can be disrespectful. We need to identify and mediate our own
individual risk factors for compassion fatigue, vicarious trauma, and burnout
(Rothschild, 2006). Hyper-vigilance,
helplessness, detachment, difficulty managing emotions and establishing
boundaries, and problems with relationships are significant signs of vicarious
trauma. Anger, cynicism, and indifference are significant signs of compassion
fatigue (Lipsky & Burk, 2009). Self-awareness
is critical. Health-science
professionals cannot afford to overlook the daily stress they encounter.
the problem: Caring Science theory
Caritas and caring science
Dr. Jean Watson is a nursing
theorist, a distinguished professor emerita and dean emerita of the College of
Nursing at the University of Colorado, and founder of the Watson Caring Science
Institute. She has given language to the mindful practice of caring in nursing
and Watson’s theory is applicable to other helping professions. Watson uses the Latin word Caritas, which is defined as love and
charity (Watson, 2008, pp. 39 – 40). Using
the term Caritas intentionally invokes for me the connection between caring and
Caring science is predicated on the
view that humanity resides in a unitary or undivided field of consciousness (Levinas,
1969; Levinas, Poller, & Cohen, 2003; Watson, 2008). The vision that we are connected with
everything allows us to observe with discernment rather than judgment.
Watson’s nursing theory of human
caring identifies 10 Caritas processes™ that give language to the practice of
human caring (Watson, 2008). I will
address my application into practice and embodiment of Caritas Process One:
Cultivating the practice of loving-kindness and equanimity toward self and
others (Watson, 2008). Caritas Process One is the foundation of
living out the theory and practice of human caring. It informs me to be present, mindful to take
a deep breath, and begin each session with the intention to cultivate a loving,
caring consciousness towards myself first in preparation to take care of others. Caritas Process One helps to evolve a new
level of consciousness by focusing on being mindfully present without judgment
and with human dignity as I discern and attend to the dynamic predictors such
as the client’s past and present ability to sexually self-regulate. This process begins with loving-kindness to
self by being conscious of my breath.
Mindfully breathing and thinking of expression of self-care such as, “I am caring … I am loving” . Then I breathe out any judgment about the
client. This may sound fluffy, but it
has helped me to be present, identify any possible counter transference, and
discern the needs of my clients.
The practice of loving-kindness to
self has been demonstrated to lower stress in probation officers who supervised
violent offenders (Giovannoni, McCoy, Mays, & Watson, 2015). In my experience, integrating human caring in
my forensic work helped me to ameliorate my stress, and decrease work related
fatigue even at my present age of 71. The
practice of human caring has personally improved collaborative relationships
with my clients, and I have experienced more disclosure and cooperation. It has also facilitated equanimity when
Dr. Watson (2008) states that
self-compassion requires the intention to practice loving-kindness and
forgiveness towards oneself. When I feel
angry and frustrated, I forgive my negative thoughts and express gratitude for
each situation I encounter, because it teaches me to become a more caring,
intuitive, and insightful therapist. I
breathe in loving-kindness for myself, and breathe out and let go of what is
beyond my control. The construct of
self-compassion has been identified by Neff (2003) in the Self-Compassion Scale
and includes factors such as: self-acceptance, life satisfaction, social
connectedness, self-esteem, mindfulness, autonomy, environmental mastery, having
a purpose in life, personal growth, reflective and affective wisdom, curiosity
and exploration in life, happiness, and optimism.
According to the principles of
Caring Science, self-compassion requires forgiving self-criticism and judgment
of self and others. It helps us to
understand that all human beings are interconnected. It teaches us to be grateful for every moment
in our lives, including the negative ones. It helps us to view difficult people as
teachers and negative experiences as providing opportunities for personal growth.
Over the past 35 years, unfortunately, I
have seen a great turnover in probation officers, parole officers, and
therapists in this field because of the stress associated with this work. I have heard colleagues say that they do not
need to care for or love their clients.
Self-compassion requires the courage to explore, acknowledge, and
address our own wounding, and revisiting the validity of long-held beliefs and
prejudices and not allowing it to interfere with our capacity for human caring. Forgiveness and authentic loving-kindness
restores our equanimity. Opening our
hearts is self-compassion and a healthier way to treat ourselves. Opening my heart with loving-kindness and
compassion has made me resilient in continuing this work.
the problem: personal practice
I am often asked why I do this
work. The simple answer is that I am committed to helping create a safer and
healthier community, free of sexual and other types of violence. I was initially trained in more
confrontational methods of relapse prevention. This never felt natural for me. I have found I am more effective in
redirecting high-risk behavior and thinking errors when my interventions are
tempered with compassion and understanding.
I began to integrate caring science
into my forensic practice, first by learning to practice loving-kindness and
forgiveness towards myself. I see my role as assisting my clients to bring
light to their darkness and to see the healing benefits of taking
responsibility and making amends to their victims and society. Reminding myself to engage with a loving
intention keeps me calm and centered as I hold them accountable. Holding my patients and their families with
reverence creates collaboration and facilitates insight and understanding. Being grateful for their cooperation is good caring
practice. The positive energy I extend
is always mirrored back to me, and it facilitates mutual respect. If I become angry or emotionally detached, I
cannot effectively serve my clients. If
my interventions are not informed by respect for the individual, I am only
dehumanizing him. This is not treatment
and may even be harmful. But when I am
compassionate and caring, I experience equanimity and I can consciously set my
intention to create a caring moment. This is more likely to create good
outcomes. I believe it is imperative that we develop a regular regimen of
self-care and self-compassion in order to uphold the dignity of our clients.
The repeated conscious practice of
loving-kindness to myself caused me to revisit some of the beliefs and
prejudices that I had developed over years of working with sexual abusers. Extending loving-kindness created a deeper
connection with my clients. I saw
results very quickly. Clients began to
share more deeply the experiences that drove them to be abusive. Maintaining good relations with clients and colleagues
requires that we first be good to ourselves. The days when I leave the office feeling good
about my work are the days when I have been loving and compassionate rather
than judgmental, thoughtful, and intuitive, and fully engaged rather than being
emotionally reactive and operating on automatic pilot. Through developing a practice of self-care, I
have created within myself a core of protection that does not create a
defensive barrier between myself and others.
My work is difficult and intense. It
requires being ever mindful of my professional code of ethics, in particular,
that I practice with respect for the inherent dignity of every person. It is important not to dehumanize patients as
they dehumanized their victims.
I have found that when I create transpersonal caring
moments, the relationship becomes synergetic and collaborative in addressing
their needs. I began to see that I was
not different from my clients. We are
all interconnected and there is a purpose for being together. My purpose is to guide them without
judgment. Guide them to make better
choices in their life that demonstrates general self-regulation, sexual
self-regulation, and concern for other.
Their purpose is to acknowledge their humanity, respect the laws for the
common good, and practice self-forgiveness by correcting the core beliefs that
they used to justify their hurtful behavior. This cognitive behavioral process of
self-forgiveness is an important part of developing compassion for self and
I use a number of techniques in my
living-out of the principles of Caring Science, which I describe in brief
The breath is one of the most
important self-care techniques. Consciously breathing helps me to stay in the
moment. The breath is a life force that
increases energy, promotes wellness, and facilitates relaxation (Angelo, 2012).
I am mindful of my breath in difficult
encounters, and with full awareness or in conjunction with compassionate
statements, it can be helpful. The
mindful practice of consciously centering on the heart, breathing in loving-kindness for self,
and breathing out and releasing fear and angry thoughts has positive
physiological effects (Homma & Masaoka, 2008; Roozendall, McEwen, &
Chattarji, 2009). Consciously taking
rhythmic breaths and focusing on our heart can facilitate our ability to
achieve a high state of heart rate variability coherence (HRVC) (Edwards, 2015). Intentionally raising our HRVC, promotes
positive emotions and we are able to send coherence facilitating intentions
towards others we are communicating with (Morris, 2010). Focusing on positive emotions has helped me
manage my stress in toxic situations with clients.
Life-affirming statements such as, “I
am loving, I am caring, I am strength, I am grace, I am safe, and I am
compassionate” have helped me to be present and restore my equilibrium in
stressful situations. It is important to
create a positive environment where you interview clients and conduct treatment. I often create posters with life affirming
messages that reflect loving-kindness and compassion for self and others with
aesthetic photographs that I have personally taken. Clients frequently tell me that these posters
give them a sense of hope and it conveys to them that I care about helping
them. When I am mindful of my breath to
raise my HRVC and I intentionally reflect on positive self-affirmations, I
experience a sense of equanimity. Then
the interview progresses smoothly, and clients leave expressing gratitude.
Meditation and mindful breathing
practices decrease inflammatory processes in the body (Rosenkranz et al.,
2013). Between sessions, I take a few
minutes to center myself to be calm and release any negative feelings that I
may harbour. When I wash my hands, I set
the intention to symbolically cleanse any negativity. I have personally found the Tibetan singing
bowl to be very helpful to signal the start of my cognitive behavioral
groups. The singing bowl has been used
as an instrument to induce relaxation and wellness for thousands of years. Research suggests that there is a consistent
spiking of alpha brain waves when the bowl is played (Plasier, 2011). Playing
soothing music can also be very helpful in creating an atmosphere of equanimity
and relaxation (McCaffrey & Locsin, 2002; Night & Rickard, 2001). When I create a calm environment and I am
fully engaged in the moment, I have the strength to make positive connections
with those who are shrouded in darkness without taking on their negativity.
Taking the time to be in nature is
one way for me to release the negative emotions that arise from working with a
challenging population. I find working
in my garden and observing how nature endures helps me to withstand the
emotional rollercoaster often experienced in my practice and sustains me to
continue this noble work. (Ulrich, Simmons, Losito, Fiorito, Miles, &
Zelson, 1991; Pretty, Peacock, Sellens, & Griffin, 2005)).
Fear, disappointment, frustration,
and helplessness can cause us to close our hearts and to become emotionally
detached toward those we are supposed to be helping. Unitary consciousness empowers us to discern
rather than judge and helps us to extend loving-kindness. First we need to practice loving-kindness and
self-compassion. This requires quiet time
through meditation, reflective practices and centering, connecting with the
beauty of nature, and self-care such as therapeutic massage and regular
exercise. We also need to let go of what
is beyond our control (Hawkins, 2012).
We need to be willing to be role
models of human caring with those who in the context of offending demonstrated
a lack of concern for others. As SSK, we
are entrusted with this noble work to promote a healthier and safer
community. To be effective and maintain
human caring, this requires self-care and the practice of loving-kindness to
yourself first before you can extend it to others. We need to express gratitude and reverence
for the mysteries of life as we continue to study and understand the cause of
sexual assault and research evidence informed methods to find solutions for
The reward is when clients
demonstrate authentic concern for others, general self-regulation, sexual
self-regulation, and the capacity for relationship stability. Former clients often reconnect with me to tell
me how the quality of their life has improved because the practicing of
loving-kindness and self-compassion has guided them to avoid high-risk
situations and facilitate caring moments in their life. The practice of loving-kindness allows me to
extend genuine gratitude and energetically gives me the ability to collaborate
with colleagues to continue this work.
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Giovannoni is a Doctor of Nursing Practice, an Advanced Practice Nurse with
prescriptive authority, and a diplomate in sex therapy. He provides holistic, compassionate,
evidence-informed patient-centered mental health treatment and pharmacological
management. He has integrated Dr. Jean
Watson’s Theory of Caring Science into his forensic practice. He conducts Sex Offense Specific Evaluations;
individual, couples, and family psychotherapy; and cognitive behavioral groups.