Vol. XXVIII, No. 4
Fall 2016
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In This Issue
Regular Features
Editor's Note
President's Message
FAQ
How can the Listserv be used for research?
Featured Articles
The reintegration of sex offenders into the community: Some observations from the front lines
Community Engagement and Partnership Working With Sex Offenders: Informing Debate and Sharing Good Practice
Jacob’s Memory and Hope: Patty Wetterling, a Mother’s Legacy
The Role of Human Caring and Compassion in Sex Offender Treatment
Students' Voice
Students Under Pressure: Improving Mental Health and Self Care
Can Researchers Measure Criminal History, Sexual Deviance, and Risk of Sexual Recidivism from Self-Report Information Alone?
Book Review
Sexual Predators: Society, Risk, and the Law
ATSA News
Adolescent Guidelines Review
Introducing Raliance – A New Prevention Initiative to End Sexual Violence in One Generation
2016 Award Winners
35th ATSA Conference
Public Engagement Event
Prevention Committee
Welcome New 2017 Board Members
ATSA Master Classes
New ATSA Members
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David Prescott
Book Review Editor

Sarah Gorter
Production Editor

Forum Editor
Contact the editor or submit articles to:

Heather M. Moulden, Ph.D.
Forensic Program
St. Joseph's Healthcare
Hamilton, Ontario, Canada
E: hmoulden@stjoes.ca
P: (905) 522-1155 ext. 35539
The Role of Human Caring and Compassion in Sex Offender Treatment
Joseph Giovannoni DNP, MA, MS, PMHCNS-BC, APRN-Rx
Honolulu, Hawaii


Background

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 population group

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.

Living out 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.

Vicarious 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.

Addressing 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 love.

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 conflict emerges.

Self-compassion

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.

Addressing 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 others.

Self-compassion techniques

I use a number of techniques in my living-out of the principles of Caring Science, which I describe in brief below.

Breath

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 messages

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. 

Mindfulness

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.

Awareness of nature

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)).

Conclusion

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 prevention.

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.  

References

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Marshall, L. E., Marshall, W. L., Fernandez, Y. M., Malcolm, P. B., and Moulden, H. M. (2008). The rockwood preparatory program for sexual offenders description and preliminary appraisal. Sexual Abuse: A Journal of Research and Treatment, 20(1), 25-42.

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Dr. 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.

 

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