key strategies for therapeutic engagement with sex...

Therapeutic Engagement with Sex Offenders 6/2/2016

David S. Prescott, LICSW 1

DavidS.Prescott,LICSWWelcome!

KEYSTRATEGIESFORTHERAPEUTICENGAGEMENT

WITHSEXOFFENDERS

Andtheresponsivityprinciple

INTRODUCTORYREMARKS

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WHAT’SOURGOAL?

• Stoppingthebehavior?

• Justiceforthevictim?

• Preventingre‐offense?

WHATWORKS?

•Dowewantthemtore‐offendornot?

•Whatcanwedo?

•Whoshouldwebe?• Isthatenough?

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ASKYOURSELF• What’sthebestsessionyou’vedoneinthepastyear?

• Whatmadeitsoeffective?

• Whatgetsinthewayofyourdoingthatallthetime?

MYMOTIVATIONProblems:

Disrespectbymanyprofessionalsoftheearliestphasesoftreatment

Implicitassumptionsofmanyprofessionals• “treatmentisaprivilege” vs.changeisaright• “Ionlyacceptyouifyouacceptmytimetableforchange.”



BEFOREYOUPAINTYOURHOME…

Thisisawakeningmotivation

Thisisthefirststeptochange

Thisismaintainingmotivation

Thisistreatment

REALITY

Weneedto…• buildwillingpartnersinchange• buildtreatmentcompleters• buildresponsivity

EFFECTIVEPROGRAMSRESPONSIVITYprinciple

effectiveprogramsarethosewhichareresponsivetoclientcharacteristics• cognitiveabilities

• maturity

• motivation

• modeofintervention

• schedulingconcerns

• neurologicalimpactoftrauma

RELATIONSHIPPROBLEMS

LEARNINGDIFFICULTIES HYPERACTIVITY



COMMUNICATIONDIFFICULTIESPARADOXICALCOMMUNICATION

You need to be more motivated to change. Treatment holds the promise of a “good life”. It is our job to point out your thinking errors;

however, it is not acceptable for you to observe when we are using thinking errors.

We expect you to demonstrate meaningful and consistent behavioral change within a highly controlled environment.

You need to participate fully in treatment regimens that we professionals cannot agree on ourselves.

COGNITIVERIGIDITY AMBIVALENCE I want to work with you, and I don’t want to

sacrifice myself I want to change, and I want to be respected I want to be in treatment, and I don’t want to be in a

one-down position I want to look at myself, and I don’t want to feel less

of a man etc. etc. etc. etc. etc.

MARSHALL,2005

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MARSHALL,2005

•Warm•Empathic•Rewarding•Directive

Problem:Manypeoplethinktheyhavethesequalities,butdon’t



Telling“TheHardTruth”• FeedbackSandwich– Affirm=>Feedback=>Affirm

• Elicit=>Provide=>Elicit– Askpermissiontogivefeedback,givethefeedback,thenelicittheclient’sthoughtsaboutyourfeedback

• Motivationalapproachesarenotnecessarilywarmandfuzzy

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Strategy#1

EMBRACEYOURBIASES!

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SELF‐ASSESSMENTBIAS

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WALFISHETAL.,2012

– Nodifferencesinhowcliniciansratedtheiroverallskilllevelandeffectivenesslevelsbetweendisciplines.

– Onaverage,cliniciansratedthemselvesatthe80thpercentile

– Lessthan4%consideredthemselvesaverage– Nooneratedthemselvesbelowaverage– Only8%ratedthemselveslowerthanthe75th percentile– 25%ratedtheirperformanceatthe90th%orhighercomparedtotheirpeers

DIRTYLITTLESECRETS

• …fromoutcomestudies

– Moredifferencebetweenthebestandtheworsttherapistswithinanytreatmentmethod,thanthereisbetween treatmentmethods

– Sometherapistsarebetterthanothers

– Hiatt&Hargrave(1995)askedtherapiststoestimatetheireffectivenessinatreatmentstudy

– TheLEASTeffectivetherapistsratedthemselvesasbeingamongthemosthelpful

AMAZING

• 581therapists

• 6,146realworldclients

• Averagesessions=10

• 46%depression,30%adjustmentdisorder,11%anxiety,plusotherdiagnoses

• Whogotthebestoutcomes?– Trainingmakesnodifference– Professionmakesnodifference– EXPERIENCEmakesnodifference– Diagnosismakesnodifference

Wampold & Brown (2005)



PROFICIENCYVERSUSEXCELLENCE

• Proficiencyinmostfieldscanbeobtainedwithin6months

• Thesamegoesfortherapy– Mostpeopleareattheirmosteffective1yearafterlicensing/registration

– Confidenceimprovesthroughoutcareer

– Competencedoesnot

• Particularlyimportantconsiderationinriskassessment

ALLEGIANCEBIAS• Professionals’allegiancetotheirmodelsandtechniquescanbeasimportantandthemodelsandtechniquestheyuse.

• Placeboeffects

• Example:goodlivesmodelversusrelapseprevention

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ADVERSARIALBIAS

• Boccaccini,Murrie,etal.– ScoresonmeasuressuchasthePCL‐RandStatic‐99rcanvaryinresponsetowhoispayingfortheevaluation.

• “Yougottadancewiththeonethatbrungya”

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OTHERCLASSICBIASES• ConfirmationBias

• FundamentalAttributionError

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THISMAYNOTBETRUE…

• Butconsiderthestatement:

• Alljudgmentisaformofviolence

• Oratleastitgetsinourwayofunderstandingourclients

• Clientswhodon’tfeelunderstoodorrespectedarelesslikelytoengagemeaningfully

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TAKE‐HOMESKILL

• Acceptandembracethefactthatyouhavethesebiases.

• Thenletthemgo…

• Andgetontotheworkofconnectingwithyourclient

• Youcanalwaysreturntothesebiaseslater!

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GETGROUNDEDINTHETHERAPEUTICFACTORSOF

TREATMENT

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THERAPEUTICFACTORS• AKA“CommonFactors”

• Factorscommontoallbonafidetherapies

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FACTORSINFLUENCINGOUTCOME VARIANCE (GRATITUDE TO JEB BROWN)

RECOMMENDEDSOURCE

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IMPLICATIONSFORPROFESSIONALDEVELOPMENT• Studyyourpopulationdeeply

• Studyeachclientdeeply

• Expertiseatengagingwithclientsinvolvesmovingfromthemicrotothemacroaswellasviceversa

• Usemodelsandtechniquesintheserviceofdevelopingyourselfprofessionally.

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USEAPPROACHGOALS

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GOALS

• Avoidancegoals:

– Associatedwithnegativeaffect,psychologicaldistress,impairmentinpsychologicalfunctioning,impairmentofself‐regulatorycapacityinsituationsofstress

– Requireconsiderablecognitiveresourcestoattainandmaintain

• Approachgoals:

– Motivateindividualtoachievedesiredstates/outcomes

– Moreeasilyattainedthanavoidancegoals

– Associatedwithpositiveaffect,reducedcognitiveload,lessdeteriorationinself‐regulatoryability,lowerlevelsofpsychologicaldistress

APPROACH/AVOIDANCE(FROMPRESCOTT/WILSON)• Idon’twantanymorevictims.

• Idon’twanttosmokeanymore.

• Idon’twantanymoretroublewiththelaw.

• Idon’twantanymoreviolencetowardsmypartner.

• Idon’twanttousedrugsoralcoholtoexcessanymore.

• Idon’twanttogambleanymore.

• Ihavebeenorderedtostayawayfromthevictimofmycrime.

• Idon’twanttobeonprobation.

• Idon’twanttolookstupid.

• Iwantpeopletobeabletotrustme.

• Iwanttobecleanandsober.

• Iwanttogetmyhealthback.

• Iwantarespectfulrelationshipwithmypartner.

• Iwanttosavemoney.

• Iwanttocompleteallmyobligationstothecourt.

• Iwanttobegoodatmyjoborgoodinschool.

• Iwanttobeabletokeepmyselfcalm.

• IwantactivitiesinmylifethatI’mgoodat(likehobbies).

TREATMENTPLANS• Mr.Xwillreducehisrisk

• Mr.Xwilltakeallhismedications

• Mr.Xwillworkonhissexualpreoccupation

• Mr.Xwillpasshispolygraph

• Mr.Ywillmanageallriskssuccessfully

• Mr.Ywillworkwithhispsychiatristtodeterminethemosteffectivetreatment

• Mr.Ywilldevelophealthysexualoutlets

• Mr.Ywillbehonestwithhimselfandothers

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FROMMYCASELOAD• Mr.Xwilldemonstratetoothersthathehaschanged

• Mr.Xwillbecomethepersonhewantstobe

• Mr.Xwillimprovehisrelationshipswithothers

• Mr.Xwillworktopreventfurtherallegations

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AndImeanreally trauma‐informed

BETRAUMA‐INFORMED

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WHATISTRAUMA?

• PTSD

• ComplexPTSD

• DESNOS

• Complextrauma

• DevelopmentalTraumaDisorder

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WHATISTRAUMA?

•Traumaisthedesperatehopethatthepastwassomehowdifferent.

• ‐‐ JanHindman

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WHATISTRAUMA?• APA:

• Trauma isanemotionalresponsetoaterribleeventlikeanaccident,rapeornaturaldisaster.Immediatelyaftertheevent,shockanddenialaretypical.Longertermreactionsincludeunpredictableemotions,flashbacks,strainedrelationshipsandevenphysicalsymptomslikeheadachesornausea.Whilethesefeelingsarenormal,somepeoplehavedifficultymovingonwiththeirlives.Psychologistscanhelptheseindividualsfindconstructivewaysofmanagingtheiremotions.

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ABSENCEOFCURIOSITY TRAUMA

• Relationalissues• Somaticchallenges



WHATISTRAUMA?

• Thegoalof(trauma)treatmentistohelppeopleliveinthepresent,withoutfeelingorbehavingaccordingtoirrelevantdemandsbelongingtothepast.

• ‐‐ BesselvanderKolk

CASEEXAMPLE

• EBTroll‐out

• JCCOdirectedclientintotreatment

• Clientreluctanttoattend

• Harm

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BENISH,IMEL,&WAMPOLD,2008• TreatmentforPTSDiseffective

• “BonafidepsychotherapiesproduceequivalentbenefitsforpatientswithPTSD”

• Muchcontroversy

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SEPTEMBER11

• CriticalIncidentStressDebriefing

• Sometreatmentscauseharm

• Lilienfeld(2007)

ULTIMATELY

Nointerventionthattakespowerawayfromthesurvivorcanpossiblyfosterherrecovery,nomatterhowmuchitappearstobein(hisor)herimmediatebestinterest.

‐‐ JudithHerman,M.D.

• Reframe:Interventionsthatempowersurvivorsfosterrecovery

POST‐TRAUMATICSTRESSDISORDER



POST‐TRAUMATICSTRESSDISORDER• Traumaticeventincluding

– Actualorthreatofdeathorseriousinjury

– Threattophysicalintegrity

– Responseofintensefear,helplessness,horror

• Persistentre‐experiencingofevents

• Persistentavoidanceofassociatedstimuli&numbingofresponsiveness

• Persistentsymptomsofincreasedarousal

• Duration>1month,significantdisturbanceinfunctioning

POST‐TRAUMATICSTRESSDISORDER• Re‐experiencingdistress

– Recollections,images,thoughts,perceptions

– Dreams

– Flashbacks,illusions,hallucinations

• Avoidanceofrelatedstimuli

– Thoughts,feelings,conversations

– Activities,placesorpeople

POST‐TRAUMATICSTRESSDISORDER• Numbingofgeneralresponsiveness

– Inabilitytorecallimportantaspectsofevent

– Diminishedinterest/participationinactivities

– Detachment/estrangementfromothers

– Restrictedrangeofemotions(e.g.,love)

– Senseofforeshortenedfuture

• Arousalsymptoms

– Insomnia,anger,hypervigilance,difficultyconcentrating,exaggeratedstartleresponse

POST‐TRAUMATICSTRESSDISORDER• Events

– Militarycombat

– Violentpersonalassault(physical,sexual,mugging)

– Kidnapping,terrorism,torture,incarceration,disasters,autoaccidents,terminaldiagnosis)

– Witnessingfatalaccident,bodyparts

• Typicallyworsewheneventisofhumandesign

• Typicallyworsewhenstressorisrepeated,chronic

IMPORTANT• NotalltraumaresultsinPTSD

• TraumacanhaveadevastatingeffectonlifeoutsideofPTSD

PREPAREMORETHANYOUTHINKYOUSHOULD

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SPECIFICSTEPS1. Getintothemindsetthatyouarecreatingnew

mindsets

2. 10,000footrule

3. Relaxyourbody

4. Loweryourshoulders

5. Slowyourbreathing

6. Rejectalldistractions

7. Spend1st 20%ofeveryinteractionengaging

8. It’shardtoarguewitharelaxedperson61

Strategy#6

PRACTICESPECIFICMOTIVATIONALTECHNIQUES

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LET’SSTARTWITHSTRENGTHS

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STRENGTHS• CASESUMMARYA

• 46,female,2children,secondmarriage;grosslyobeseformanyyears;leadsaninactivelife. Moderatetoheavydrinker,smokes15+aday,andhasadietthatishighinfriedfood,withlittlefruitorvegetables.

STRENGTHS

• CASESUMMARYB

• 46,accountmanagerandmotheroftwo;verydeterminedperson. Itshersecondmarriage,andshekeepsakeeneyeonherchildren’swell‐being. It’sahappyhouse. Theyworkandplayhard. Shehaslotsoffriends,smokesanddrinksinthepub,andgetslittleexercise. Shelikestomakesureeveryonehasagoodfillingmeal,andthisoftenmeansfriedfood.

STRENGTHS• CASESUMMARYC

• Dan,16.5,enteredresidentialtreatmentafterhemolestedhistwoyoungersiblings,onemaleandonefemale.Healsophysicallyassaultedhismother,whichhasledtolong‐termconcernsastowhetherhecanreturnhome.Danhatestreatmentandcomplainsthatheshouldhaveaccesstoagrandpiano,becausehistreatmentisinterferingwithhisfuturecareerasamusician.Danhasintensedifficultygettingalongwithothersandoftenviewsthemasstupid.



STRENGTHS• CASESUMMARYD

• Danisalmost17.Heisveryseriousabouthisfutureasaclassicalmusiccomposer.However,hehasgreatdifficultygettingalongwithothers.Hewantsdesperatelytohavefriends.Hisgrowingupinahousewherehewasbeatenbyhisfather(beforehisfatherbecameincarcerated)haslefthimwithabeliefthathehastofighttogeteven.Curiousaboutsexandwantingtofeellikeaman,hemolestedhisyoungerbrotherandsister,andphysicallyassaultedhismotherwhenherealizedshewasgoingtohavehimplacedoutsideofherhome.Danwantsnothingmorethantofindhiswayoutofhiscircumstances,andthatmeansgettingasolidmusicaleducationandpracticingpiano.

FINDTHESTRENGTH

FINDTHESTRENGTH FINDTHESTRENGTH





ALITTLEHARDER

• FindtheStrength

HARDERSTILL

• FindtheStrength

2013PRACTITIONER’SDEFINITION

• Motivationalinterviewingisaperson‐centeredcounselingstyleforaddressingthecommonproblemofambivalenceaboutchange.

THESPIRITOFMOTIVATIONALINTERVIEWING

•Partnership•Acceptance•Compassion•Evocation



FOURPROCESSES

–Engaging–Focusing–Evoking–Planning

THESEPROCESSESARE…• Somewhatlinear– E.g.,engagementcomesfirst

• Andalsorecursive– EngaginghappensthroughoutMI– Focusingisnotaone‐timeevent;– Realtreatmentinvolvesre‐focusing– “testingthewater”onplanninghelps

TALK

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

SustainChangeCommit

Thereisnosuchthingas“resistance”

Thereis discordandsustaintalk

“I’mnotgonna;youcan’tmakeme”

CHANGETALK

• Desire“Iwantto…”

• Ability“Ican…”

• Reason“Therearegoodreasonsto…”

• Need“Ineedto”

RESPONDINGTOCHANGETALK

• Whenyouhearchangetalk,don’tjuststandthere!

• Elaborate(tellmemore)

• Affirm

• Reflect

• Summarize

SKILLS HowcouldImakethisproblemworse?

Howdoesthebehaviormakesense?

Whatareallthewayshe/shefeelstwowaysabouthis/herlife?

Whatarethepositivegoalsforchange?



TAKE‐AWAYMESSAGES Creatingnewmindsets

Goslowandlistenlong

Spend20%ofsessionengaging

Lookforclientconfirmation

Listenforambivalence

Dancewithdiscord

Respecttheunexpected

Bemulti‐modalanduseyourspace• YOUarethemostinfluentialpresence

key strategies for therapeutic engagement with sex...

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