Vol. XXX, No. 4
Fall 2018
Text Only Version
In This Issue
Regular Features
Editor's Note
President's Message
FAQ
Is there such thing as “sexual harm” or is it always Abuse or Trauma?
Featured Articles
Moving beyond the “sex offender” dialogue:
How ATSA members can promote person-first language
Pros and Cons of Manualized Approaches to Sexual Abuse Specific Treatment:
Experiences of Programs in Kansas & Oregon
The Clinical Practice Corner: Juvenile Practice
The ATSA Adult Clinical Practice Committee
Students' Voice
The ATSA Student Experience:
A Personal Anecdote on Attending the Conference and Joining the Student Committee
Book Reviews
Two by Jeglic and Calkins
The Safer Society
Handbook of Assessment and Treatment of Adolescents Who Have Sexually Offended
ATSA News
2018 ATSA Conference Events
Public Engagement Event
Welcome Incoming Board Members
2018 ATSA Awards
New ATSA Members
Newsletter Tools
Search Past Issues
Print-Friendly Issue
Print-Friendly Article
Forum Team
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
Pros and Cons of Manualized Approaches to Sexual Abuse Specific Treatment:
Experiences of Programs in Kansas & Oregon
Katherine Gotch, Tiffany Looney, Seth Wescott & Marc Schlosberg


Katherine Gotch


Tiffany Looney


Seth Wescott


Marc Schlosberg

There has been a recent movement, often driven by policy makers and/or correctional agencies, in varying jurisdictions within the United States for the manualization of sexual abuse specific treatment programming. The reasons for this movement have been identified as fiscal, to strengthen evidence-based practices, and/or to address resource limitations such as a lack of qualified clinical staff in rural areas. However, what are the benefits and deficits for implementing this type of scripted manualized approach?

The Kansas Experience:

The Kansas Department of Corrections (KDOC) contracts with a private, for-profit agency (Clinical Associates) to provide sexual offense specific evaluation and treatment services for incarcerated offenders and parolees throughout Kansas. Clinical Associates is the sole-source provider for these services and treatment is conducted at four correctional facilities and seventeen outpatient locations across the state. In 2014, following trends in correctional practices, KDOC asked Clinical Associates to implement a scripted manualized curriculum. The rationale for switching from an individualized, risk/need/responsivity approach to a scripted manualized approach was based on Kansas data which suggested that, although recidivism for sexual offenses was quite low (less than 3%), parole revocations for technical violations was much higher (close to 40%) and that a structured, skills-building approach would better assist in the reduction of criminogenic needs and lead to greater success on parole. The KDOC identified a specific curriculum to be utilized and training on the curriculum occurred in early 2015, with program implementation occurring in the spring of 2015. The first cohort finished treatment in summer 2015. Implementation proceeded slowly due to logistical issues within facilities, and only 8% of all those who completed in Fiscal Year 2016 (FY16) had received the manualized curriculum. By the conclusion of FY17, that number had climbed to 68%. In FY18, 73% of all those who completed the program had received the curriculum.

Clinical Associates’ theoretical model was previously grounded on the principles of risk, need, responsivity; utilized Good Lives Model approaches; promoted healthy sexuality; focused on increasing personal accountability and decreasing dynamic/criminogenic areas of need; and used the polygraph to validate self-report. From 2011 to 2015, Clinical Associates provided facility-based programs in three prisons (and expanded to include a fourth facility in 2018). These programs lasted from four to six months (based on level of risk) and involved group and individual sessions, as well as non-traditional interventions/programming for responsivity issues for individuals who possessed high psychopathy, low intellectual functioning, and/or severe and persistent mental illness. Seventeen outpatient offices provided community-based programming which lasted from six to twenty-four months (based on level of risk) and involved group and individual sessions, as well as non-traditional interventions/programming for responsivity issues. All treatment programs were individualized and focused on stable risk factors, criminogenic needs, intimacy deficits, sexual deviancy, and pro-offending attitudes.

Since 2015, the scripted manualized curriculum has been the required programming that Clinical Associates provides within all facility-based programs and has been piloted in the community. As noted previously, a main driver for implementation of the manualized curriculum was to address parole revocations for technical violations as it was the belief that a structured, skills-building approach would better assist in the reduction of criminogenic needs and lead to greater success on parole. However, the initial data compiled by Clinical Associates has demonstrated that this goal has not yet been achieved. Additionally, as there is no longer the flexibility to individualize programming based upon the principles of risk, need, responsivity, the scripted manualized curriculum has a higher overall cost (see below).

Kansas Outcome Data

FY16

FY17

FY18

Completions

281

191

219

Cost per Completion

$3197.15

$4703.66

$4102.28


The primary responsivity issues addressed in the required curriculum are poor motivation and resistance. There are no guidelines or suggestions for altering the curriculum for individuals who are lower functioning, who have severe and persistent mental illness, or who present with high psychopathy.

Clinical Associates utilizes the polygraph as a component of treatment. In the facility-based program, participants complete and process a sexual history in preparation for the sexual history disclosure polygraph. In order to prepare participants for the sexual history assignment, treatment time must be devoted to discussing specific sexual behaviors, a topic not addressed in the curriculum.

Although the required curriculum is reported to be rooted in the risk, need, responsivity principles, the scripted curriculum itself allows for minimal variability among the different risk levels. While the curriculum is designed for use with individuals of above average and well above average risk (formerly moderate high and high risk categories), there is not a published low dosage version for those who are average or below average risk. Clinical Associates assesses all participants prior to program entry, and their Static-99R and STABLE-2007 scores are noted. Kansas’ data suggest that approximately 28% of offenders score above average or well above average risk on the combined Static-99R/STABLE-2007, leaving the majority of offenders (approximately 70%) outside the recommended criteria for participation. Rather than provide treatment to only 28% of sexual offenders, Kansas chose to include those who were average and below average risk, while excluding only those assessed as very low risk. This has resulted in a treatment program challenged to maintain best practices due to the primary curriculum it is currently required to use.

The Oregon Experience:

In Oregon, there are no institutional sexual abuse specific treatment programs and treatment services are typically provided after an individual has completed all in custody sanctions and is placed on community supervision (probation, parole or post prison). Community corrections in Oregon is also primarily county versus state managed, meaning that each county has the choice of how they may implement or pilot new programs or services within their jurisdiction. A level of statewide consistency is maintained through the Oregon Association of Community Corrections Directors (OACCD), as well as the statewide Sex Offender Supervision Network (SOSN), a multi-disciplinary professional network which guides best practice standards for sexual offense specific supervision and management.

McKenzie Counseling is a community-based agency providing sexual offense-specific treatment in Lane County, the second-largest metro area in Oregon.  McKenzie Counseling was required to pilot a scripted manualized curriculum as a condition of the contract with the Lane County Parole and Probation Department.  Several other sexual offense specific treatment programs around the state also participated in the pilot project, with varying degrees of fidelity as some programs had the ability to implement the curriculum with considerable flexibility, integrating aspects of the manualized approaches into their existing programming.  McKenzie Counseling was required to conduct a pilot with strict adherence to the scripted manual, delivering all modules completely and in sequence, without use of other materials or interventions. 

For logistical reasons McKenzie Counseling conducted the pilot as an open group, with 14 participants at the outset.  All participants scored moderate or higher on a validated risk assessment instrument (Static-99R or LS/CMI).  Attrition was 50% for the initial group due to issues with motivation, supervision violations or absconding supervision, substance use, and lack of attendance or homework completion.  Due to these attrition issues, new participants were added at open modules, keeping the group size at approximately 12 for the duration of the pilot.  Two state certified sexual offense specific master level clinicians facilitated all service delivery of the manualized curriculum. 

Although marketed as a sexual offense-specific intervention and program, it was noticeable that the scripted manualized curriculum did not directly address sexual self-regulation criminogenic needs or sexuality more broadly.  For this reason, clients selected for the pilot were those who presented with predominantly general criminogenic risk/need profiles versus those presenting primarily with sexual self-regulation needs. As such, it was recognized from the onset that these individuals were not a representative sample of adult males convicted of sexual crimes and, therefore, the generalizability of the outcome data would be limited.  However, McKenzie Counseling felt an ethical obligation to place clients whose primary areas of need related to sexual self-regulation into treatment groups where those issues would be addressed.

The manualized curriculum was presented in its entirety, as scripted, with a few exceptions.  The manual directs facilitators to limit check-in time at each group to no more than 10 minutes.  It was necessary to do away with this limitation to adequately address the concerns of our high-needs, high-responsivity clients.  Additionally, the clinicians were not comfortable treating clients without the opportunity to conduct ongoing screening for acute risk factors or have a general idea of what was pertinent in their clients’ lives in the moment.  From a more philosophical standpoint, the clinicians additionally disagreed with abdicating the transactional nature of a therapeutic interaction in favor of a unidirectional, solely didactic approach.  Ultimately, it was decided to extend the group from 90 to 120 minutes to provide adequate time to address clients’ current concerns and still meet the structured time for delivery of the manualized curriculum for each session. Client feedback revealed support for this choice as captured by this client’s statement: “If we didn’t get to check in, it would feel like all you cared about were the lessons, and not about us.” 

Client feedback was solicited at regular intervals throughout the pilot project with the clients reporting that they found the skills useful in their daily lives and also appreciated the goal-oriented nature of the sessions.  The group sessions were interactive and generally lively, with group members appreciating that everyone was working on the same thing, at the same time.  However, many of the participants also found the format repetitive and reported greater benefit when they received more explicit instruction for the skills taught. From a facilitator perspective, observed engagement was generally good, even for those clients about whom there were initial concerns regarding lack of motivation.  The manualized materials appeared to be a good fit for clients with a more concrete cognitive style, as well as those who are less sophisticated or psychologically-minded. 

However, the manual often read like a rough draft, with typographical errors, unclear directions, and sections appearing to have been cut and pasted directly from the substance abuse treatment curriculum developed by the same authors.  Rigid lesson structure made it exceedingly difficult to address client responsivity factors, while reading from a script felt artificial and demeaning for licensed mental health professionals.  There were additional instances where it was necessary to spend considerable time with certain clients individually, to address current issues that there was not time for in group.

Going forward, McKenzie Counseling intends to continue facilitating a group that works predominantly from the manual (with modifications) for clients whose dominant areas of need are related more to general criminogenic factors versus sexual self-regulation.  McKenzie Counseling additionally intends to integrate aspects of the curriculum which was found most useful into our broader program as there are features of the materials which, when delivered with flexibility and in accordance with the principles of Risk-Needs-Responsivity, would serve to promote the mission of enhancing community safety by delivering evidence-based programming to reduce recidivism risk and promote the welfare and quality of life for the clients served.               

Best Practices in Sexual Abuse Specific Treatment:

As outlined within the ATSA Adult Practice Guidelines[i], sexual abuse specific treatment is designed to assist clients to effectively manage thoughts, fantasies, feelings, attitudes, and behaviors associated with their potential to sexually abuse. In addition to reducing risk for sexual and/or non-sexual recidivism, treatment is designed to assist clients to develop a prosocial lifestyle that is inconsistent with offending. It is also recognized that effective sexual offense specific treatment incorporates the risk, need, responsivity (RNR) principles, and that sexual offense specific treatment services are matched to the assessed recidivism risk and treatment needs of a given client – individualization of treatment programming based upon validated risk/need assessment, as well as responsivity factors, has become the gold standard within sexual offense specific treatment.

Additionally, research has demonstrated that programs which adhered to the RNR principles showed the largest reductions in sexual and general recidivism[ii]. This indicates that RNR principles should be a major consideration in the design and implementation of treatment programs for individuals convicted of sexual crimes. Specifically, clinicians need to be allowed the freedom to individualize treatment by tailoring the dosage of services to the level of risk for a given client (risk principle); address dynamic risk/need factors as the primary framework for treatment (need principle); and adapt service delivery to meet the individualized treatment needs of clients in order to maximize their ability to learn (responsivity principle).

Pros & Cons of Scripted Manualized Programming

Based upon the experiences of Kansas and Oregon, the following conclusions were made regarding the pros and cons of the scripted manualized curriculum:

Pros:

  • Structured and standardized approach
  • Modules are content-specific and cumulative
  • Skills taught are helpful for daily life
  • Clients work on the same things at the same time
  • Skills facilitate healthy communication
  • Connect the dots: Thoughts/Feelings/Behavior
  • Deals with lack of motivation
  • Good use of visual aids
  • Teach skills that address criminogenic needs to reduce revocations

Cons:

  • Where’s the sex?
  • One size fits all - again?
  • Time constraints
  • When do we talk about risk?
  • Instruction against modifications
  • Extends treatment time
  • No outcome data
  • Does not adequately address responsivity
  • Some clients do not need these social skills
  • Does not incorporate or address trauma-informed practices
  • Does not adequately address risk/need factors that have been linked to sexual recidivism

Final Thoughts:

While there is potential utility for the scripted manualized curriculum implemented in Kansas and Oregon, it does not adhere to the principles of risk, need, responsivity or reflect best practice guidelines for sexual abuse specific treatment; therefore, the curriculum should not be identified or marketed as such. Based upon the experiences of Kansas and Oregon, it is recommended that if a scripted manualized curriculum is to be used, it should be incorporated as part of a larger sexual abuse specific treatment program, specifically the cognitive component and/or applicable exercises and handouts rather than as a stand-alone intervention or approach. The evolution of sexual abuse specific treatment has taught us that individuals convicted of sexual crimes present with differences in risk, treatment needs, motivation, and protective factors. If we accept the differentiation among those we treat, we must also make room for differentiated and individualized treatment. 



[i] Association for the Treatment of Sexual Abusers. (2014). Practice guidelines for the assessment, treatment, and management of adult male sexual abusers. Beaverton, OR: Author.

[ii] Hanson, R.K., Bourgon, G., Helmus, L., & Hodgson, S. (2009). The principles of effective correctional treatment also apply to sexual offenders: A meta-analysis. Criminal Justice and Behavior, 36(9), 865-891.

 

Previous Article
Next Article
ATSA | 4900 SW Griffith Drive, Suite 274, Beaverton, OR 97005 | Contact Us

To ensure delivery, please add 'sarah@atsa.com' and 'sarah@atsa.mmsend.com' to your email address book. If you are still having problems receiving our emails, see our whitelisting page for more details.

Click here to unsubscribe
Members Menu ATSA Journal ATSA Conference Update Your Information Home