Treating Dynamic Needs
Sex Offenders with
Cognitive Impairments
&
Serious/Persistent Mental Illness
Mary Owen, LCSW-R
Chief of Service, SLPC – SOTP
Jayme Smith, Psy.D.
Licensed Psychologist, SLPC -SOTP
Learning Objectives

Examine best practice strategies for training
individuals with Cognitive Impairment (CI) & Severe
& Persistent Mental Illness (SPMI) in order to
understand implications for staffing & treatment
delivery

Integrate knowledge of Dynamic Factors into
treatment practices for the CI & SPMI populations
Defining the Population

Sexual abusers

Moderate to high sexual recidivism risk

Cognitive impairment

Serious and persistent mental illness
Bridgeview Diagnoses

Sexual Disorders 100%


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
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Pedophilia 64%
Paraphilia (Rape, Sadism…) 36%
Borderline Intellect 35%
Psychotic Disorders 25%
Personality Disorders:

Antisocial 45%
NOTE: Most common age range: 41-60
COMMON MISCONCEPTIONS
ABOUT SPMI AND CI SEX
OFFENDERS AND TREATMENT
Facts About SPMI and CI Sex
Offenders




Sex offenders w/ SPMI constitute about 8%
of all men charged in a sex offence
SPMI sex offenders are more similar than
different from most offenders (Sahota & Chesterman, 1998)
Not all SPMI offenders are driven to offend by
the illness (Smith, 2000)
Individuals with lower IQ’s are less prone to
violence in offending
(Murray et.al., 1992)
Factors That May Not Be
Related To Sexual Recidivism



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Victim empathy
Denial/minimization of sexual offence
Lack of motivation for treatment
Internalizing psychological problems

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Anxiety, depression, low self-esteem
Sexually abused as a child
Low conventional ambition
Insufficient fear of official punishment
SEX OFFENDER TREATMENT
CLIMATE
Setting the Treatment Climate

Traditional approaches to sex offender
treatment are NOT effective!




Aggressive
Confrontational
Hostility
“Hot Seat”
Setting the Treatment Climate

General best practice applies


Past separation of SO treatment and traditional therapy
techniques and beliefs
Therapeutic relationship as a curative factor
(Norcoss, J., 2002;
Horvath and Symonds, 1991;Frank & Gunderson,1990; Krupnick, et al. 1996)

“Improvement in psychotherapy may best be accomplished by
learning to improve one’s ability to relate to clients and
tailoring that relationship to individual clients.” (Lambert and Barley, 2001)

Especially important for SMPI
Setting the Treatment Climate

Therapist characteristics influence treatment
gains
(Marshall, et al., 2002)

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Empathy
Warmth
Directive
Rewarding
Firm but supportive challenging
Setting the Treatment Climate

Hopelessness is a huge issue in civil
confinement centers



Find a realistic goal that keeps hope alive
Increased hope is associated with reduced
risk for re-offending (Prescott, 2009)
Build best context where clients can change
(Mann, 2009)
TREATMENT FOUNDATION
COACH vs. KEEPER


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Focus on individual, not illness
People change behavior for things THEY
want
Change occurs in stages & is tied to trust
Positive outcomes can be crafted w/o
changing the person
Work from a place of respect
FRAMING SO TREATMENT
General Goals of SO Treatment

Eliminate sexually assaultive behavior

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Reduce deviant sexual arousal
Reduce criminality
Correct distorted thinking
Increase adaptive functioning

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Increase interpersonal skills
Increase openness & trust
Broaden interests beyond sexuality
Educate about healthy sexuality
Treatment Specific to Sex
Offenders - Model

RNR Model

Risk
 Level of risk considered with level of treatment



(Andrews, Bonta & Hoge, 1990, 2006)
Low risk vs. high risk
Need
 Criminogenic Needs
Responsivity
 Tailor treatment to offender

Includes learning style, strengths, weakness, culture
Good Practice

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Target treatment to the whole person
Focus on dynamic risk factors
Emphasize dynamic growth
Manage symptoms
Train to learning styles
ASSESSMENTS TO INFORM
TREATMENT
SO Treatment Specific for CI
and SPMI - Assessments

Assess for psychopathy

Sexual deviance combined with psychopathy = increased
risk of reoffense (Gretton et al. 2001; Harris et al., 2003)

Assess IQ and the parameters of impairment

Assess adaptive and social functioning


Vineland Adaptive Behavior Scale
Can help to determine more about motivations of sexual
crime
SO Treatment Specific for CI
and SPMI - Assessments

Thorough clinical interview


Assess severity psychiatric symptoms
Clarify how psychosis is tied to sex offense

Psychiatric Evaluation

PPG
Initial Steps in SO Treatment
for CI and SPMI

Stabilize psychiatric patients


Re-evaluate content of delusions to see if sexual
beliefs have become more pro-social
Review assessments to develop case
conceptualization

Basis of treatment planning
Case Conceptualization
Gain deeper understanding of why the
consumer committed the sexual crime

Psychopathy = meeting needs without regard for
others


Align pro-social goals and self-interest
Sexual deviance – sexual orientation towards
children


Evaluate for appropriate sexual arousal
Focus on reconditioning / anti-androgens
Case Conceptualization

Psychosis-based sexual beliefs


No improvement of delusions while medicated
 External management
 Safety planning
Poor Social Skills / Developmentally Delayed

Focus on sexual education, social skills and safety training
 ‘Counterfeit deviance’ hypothesis
 More rare
TREATING DYNAMIC RISK IN
OFFENDERS WITH SPMI
Dr. Thornton says….
“The presentation argues that the psychological risk factors which
we usually think of as dynamic generally function more like
enduring traits so that they change only slowly and with difficulty.
However, there is evidence that targeting psychological risk factors
related to recidivism is more helpful than targeting other factors
and that treatment participants can learn to manage these
enduring traits more effectively so that those who manifest them
less in environments that challenge the traits go on to show less
recidivism than those who continue to manifest them.”
Dynamic Risk Factors
Mann, Hanson & Thornton (2008)

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Sexual Preoccupation
Deviant Sexual
Interests
Offense Supportive
Attitudes
Emotional Congruence
with Children
Poor Adult Attachment

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Lifestyle Impulsivity
Resistance to
Supervision
Poor Problem Solving
Grievance Thinking
Hostility
Negative Social
Influences
ADDITIONAL CONSIDERATIONS

Self-regulation

Social Skills

Medication Adherence
Practical Applications

Disclosure

Autobiography

Relapse Prevention Plan
Features of Mental Illness

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Lack of stable identity
Disorganized thinking
Vulnerability to stress /
Changes in the
environment
Difficulty solving
problems

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Poor self-care
Social withdrawal
Abandonment of family
responsibilities
Work incapacity
Schizophrenia and Cognitive
Dysfunction
Most common difficulties:
 Attention
 Memory
 Executive functioning
Note: those with negative symptoms often have
more cognitive difficulty
SPMI & SO Treatment



More open about sexuality
Increased sexual dysfunction (ED)
Increased faulty sexual knowledge
(Hughes & Hall, )
SPMI is a disinhibitor – increases criminality,
substance abuse, poor social skills, stranger
victims
(Sahota & Chesterman, 1998)
Factors Associated with
SPMI Resiliency



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Good self esteem
Impulse control
Adequate social skills
Ability to problem solve
Good coping skills

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Ability to delay
gratification
Ability to manage stress
Skill building
Social Support
BEST TREATMENT STRATEGIES
Sexual Preoccupation

Promote Wellness Management (Self monitoring
checklist)

Inform on observation of arousal

Thought stopping

Arousal Reconditioning

Consider medications to reduce arousal (SSRI, AAT,
Clinician support in psychiatry consults)
Deviant Sexual Interests

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ID tie-in between delusions & deviance
Journaling / charting (adaptive assist PRN –
recorder
Need vs. want / rational disputing
Thought stopping
Arousal reconditioning
Consider medications to reduce arousal (SSRI, AAT,
Clinician support in psychiatry consults)
Offense Supportive Attitudes

Group process (Autobiography, Self
Disclosure)

Cognitive restructuring

Confront & supply data

Self report to evaluate
Emotional Congruence w/
Children

ID perception problems
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Self perception
How others see you
Use of video to self assess
Could you see….
Environmental structuring
Increase adult social / leisure skills
Poor Adult Attachments

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Develop support network (family, faith,
providers…)
Whole family education & advocacy
Social skills training
Appropriate relationships with staff members
Increase ability to be intimate
Problem Solving

Develop partnership (supportive presence;
collaborative problem solving)

ID skill for development (model, role play, practice,
performance feedback, real life practice)
Grievance Thinking/Hostility


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Cognitive restructuring
Find the emotion driving this
Immediate feedback
Rating Scale


1 (not upset) – 10 (very upset)
Check perception against the group or therapist
Negative Social Influences

Observation in treatment setting/community

Help structure routines (ID options for activity,
provide choices, schedule of daily activities)
 Case Management
 Day Treatment/Social Club

Formal contingencies

SIST

ACT Team
Kendra’s Law

Self-regulation
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Impulse Control Training
Motivation for Treatment
Medication
DBT
Pointing for Boundaries
COGNITIVE IMPAIRMENT
Static and Dynamic Factors
(Lindsay, Elliot & Astell, 2004)

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Anti-social Attitude
Poor Response to
Treatment
Offenses Involving Physical
Violence
History of Violence
Staff Complacency
Deterioration of Family
Attitudes
Unplanned Discharge

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Poor Maternal Relationship
Low Self Esteem
Lack of Assertiveness
Attitudes Tolerant of
Sexual Crimes
Low Treatment Motivation
Erratic Attendance and
Unexplained Breaks from
Routine
Static and Dynamic Factors –
Differences

The following factors MAY NOT be associated for
recidivism in CI population:



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Employment History
Criminal Lifestyle
Criminal Companions
Diverse Sexual Crimes
Victim Choice
(Lindsay et al., 2004)
Practical Applications

Disclosure

*Denial*

Autobiography

Relapse Prevention Plan
Standards of Care for CI


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Positive relationship
Person-centered care
Consistency of services (long term case
manager – even when hospitalized)
Team-based service
Family participation to increase therapeutic
reach
Cognitive Impairment
(Horton & Frugoli, 2001)
Modalities to Use:
Psych-Ed (use pictures, art, role play, audio music)
Narrative
& Storytelling
Family Work
Skill Building/Practice
Individual Work (to increase comprehension and
reinforce/homework)
Anti-social Attitude

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Token economy
Align pro-social actions with their goals
Emphasize rewards for pro-social behaviors
Consistent and immediate consequences for
anti-social behaviors
Low Self-Esteem
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Social skills training
Emphasis on positive
Skills training
Sexual education
Attitudes Tolerant of Sexual
Crime

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Cognitive restructuring
Group process
Sexual education
Model & enforce clear rules / boundaries
Set positive expectations
Resource: Footprints
Staff Complacency

Do not excuse behavior due to CI

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Remember that this population can change
Clinical staff must be in contact with ward
staff to reiterate expectations
Hold staff members accountable
Deterioration of Tx Compliance
Low Tx Motivation

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Investigate reasons for this
Reassess responsivity needs

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Wrong treatment modality
External motivation for treatment
Structure successes
Psychiatric consultation
Violence

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Anger management
Root causes
Psychiatric consult
Reduce stimuli
Deterioration of Family

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Encourage contact even w/o consent. We
can always listen & use good information
Ask how they prefer to receive information
Ask their perception of the illness,
experiences and priorities in care/treatment
Assume they’ll be involved long after you are
gone
Share stories & encourage peer support
Poor Maternal Relationship

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Family psycho-education on sexual offending
Multi-family psycho-education to bring
supports into collaborative problem solving
Lack of Assertiveness

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Establish therapeutic alliance
Set goals with the person
Behavioral rehearsal
Positive reinforcement
Shaping & prompting
Modeling
Homework & practice
Erratic Attendance and Unexplained Breaks from
Routine

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Provide/promote routines, structure and
consistency
Develop short commands to eliminate
impulsive actions “stop”
Demonstrate and promote practice of
procedures and sequences taken in
everyday problem solving situations
Offer guiding questions (What's the first
step? What do you do next?)
SKILL TECHNIQUES
Important Note

Many of the previous interventions are
consistent with best practices for treating
SPMI & CIs.

You are on the right track!
Common Impairments in
Cognition or Thinking with Mental
Illness

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Memory
Attention-span
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
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Ability to focus/Concentration
Multitasking
Processing speed
Problem solving
Language
Visual-Spatial/Visual-Motor Processing
Strategies to help memory

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Repeat information/instructions
Present one new concept at a time
Ask person to repeat or paraphrase what you
have just said
Put new information into context (everyday
examples)
More Strategies to help
Memory

Put things in writing/encourage person to
write down important information to be
remembered

Use memory aides: calendars,
notebooks/diaries, pill containers, watch
alarms, sticky notes
Strategies to help attention

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
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Use the person's learning style (auditory or
visual)
Keep it simple (be direct, short and to the
point)
Only one task at a time.
Make things interesting (use voice, change
tone, volume, gesture)
Decrease distractions (noises, activity)
More Strategies to help
Attention



Use direct eye contact and sense of touch
can be used once attention is gotten and to
sustain involvement
Provide a balance of activities across
physical, mental and social domains
Allow more time to complete tasks
Strategies to help Executive
Functioning




Provide/promote routines, structure and
consistency
Develop short commands to eliminate
impulsive actions “stop”
Demonstrate and promote practice of
procedures and sequences taken in everyday
problem solving situations
Offer guiding questions (What's the first step?
What do you do next?)
More Strategies for Executive
Functioning




Provide frequent encouragement and praise
for actions that are initiated, attempted,
maintained
Give specific feedback regarding behavior
(provide an explanation for why the strategy
is incorrect and offer alternatives)
Use self talk by verbalizing out loud
Observe actual performance when assessing
skills
Social Skills Training


Rehearsals
ID & Develop Circles of Support
Techniques for Managing
Cognitive Dysfunction

Total communication

Compensation strategies

Adaptive approaches
Setting

Low stimulus environment

Few Distractions

Frequent Rest Breaks

Keep group time short or modify 1:1 time
Teaching Approach



Structured Instruction
Presented in Variety of Formats
Focus on:




Adaptive Skills
Coping Skills
Keep Pace Slow
Repeat Information Frequently
Strategies to help language
Comprehension:

Keep things simple, direct, short and to the
point

Speak concretely not abstractly

Try explaining things in a different way
Groups as Experience vs.
Lesson






Slow processing
Clarify before, during, after
Don’t use all CAPS in handouts
Do you think you may have sexual thoughts
about…?
STOP drawing if deviant (rehearsal)
Arousal – Notice, promote thought stopping
Conduction Group Sessions


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
Start by focusing on a picture
What is happening?
What is the person doing? Thinking?
What will happen next?
IDENTIFY GOALS/PROBLEM
AREAS FOR SESSION

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Anger Management
Problem Solving
Help clients define problems by asking “what, who,
where, when.”
1-2 specific problem areas for session.
Examples: Initiating conversation, disagreement
with medication, angry at staff behavior. Using free
time, telephoning family/others, managing money…
COACHING REHEARSALS

When demonstrating “how to say” something while a rehearsal is in
progress, use non verbal hand signals:


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
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
Stop….hand up
Slow…..two hands, taffy pull
Speed Up…one finger making a circle
Smile or look serious….hands at corner of mouth, up or down.
Good job…..thumbs up
Talk louder, softer…….palms up/down
Eye contact…..finger to eye
When demonstrating “what to say” during rehearsal, stand close and
whisper in client’s ear. Make sure this is OK with the client. Usually the
coach’s close proximity to the client during the scene gives support and
encouragement.
ASSIGN & CHECK
HOMEWORK





Make out individual assignment cards.
Give clear instructions, keep it simple, give
real life assignments.
ID any obstacles in carrying out the
assignment.
Praise success.
Document results
IMPLICATIONS FOR STAFFING &
TREATMENT DELIVERY
Tools to Support Responsivity
Needs






Staff training on teaching techniques
Targeted modules / Simplified learning
packets
Multi-modal equipment
Smaller processing more rehearsal
Need for smaller groups
Shared treatment resources
Vicarious Trauma



Not so much a question of if, more a question
of when
Provide clinical supervision and support for
therapists
System wide