The Way Forward for Sex
Offender Treatment (?)
Anthony Beech
Dawn Fisher (alternative approaches)
1
Overview
The aim of the presentation is to suggest ideas
in terms of what could be the way forward for
sex offender treatment
– noting that we are all products of our brain
development and brain function
– Incorporating ideas from the rapidly advancing
field of neuroscience
– And what this says about other approaches to
therapy, as adjuncts to current cognitivebehavioural treatment
2
Embodiment
• There may be no brain parts for cognition, not least separate
from the brain mechanisms pertaining to bodily functions
(Tucker, 2007)
• According to Tucker he neural structures of the mind exist to
construct information, by constructing concepts that relate
internal personal need to external environmental reality
– In its most basic form personal need is represented within the emotional and
motivational networks within the limbic core cortical areas in the brain
– While data from the world is are interfaced by the sensory and motor areas in
each cerebral hemisphere
– Between these boundaries the brain constructs the ‘information of mind’
through linked patterns of meaning, woven across each cerebral hemipshere’s
corticolimbic network
3
Is it important to think in a neurobiological
way in terms of treatment for sex
offenders?
• Some neurobiological markers in pedophilic sex offenders
indicative of early trauma:
– Lower IQs (Cantor et al., 2004)
– Poorer visuospatial and verbal memory scores
– Higher rates of left handedness (Canter et al., 2005, 2005)
– Higher reported rates of having reported childhood head
injuries (Blanchard et al., 2002, 2003)
– More likely to have been placed in special education
facilities
4
The neurobiology of trauma
• Advances in technology have enabled a much greater
understanding of neurobiology in recent years
• Use of fMRI, PET, MRS, EEG, SPECT & Diffusion Tensor Imaging
(fibre tracking)
• Studies have found differences in the brains of traumatised
humans and animals compared to controls
• Trauma affects memory, learning, ability to regulate emotion,
social and moral development
• Trauma causes both immediate and long-term endocrine
changes that affect metabolism and neuropsychology
• Even high levels of cortisol (caused by stress) can have very
real effects upon the brain
5
Adverse early experiences
• In fact we are programmed by adverse early
experience to have:
– an enhanced cortisol
– norepinephrine/adrenaline
– vasopressin response
– and decreased oxytocin response to subsequent
stressors.
6
The neurobiology of trauma 2
• Traumatic events overwhelm the brain’s capacity to process
information
• The memory may be dysfunctionally stored in the right limbic
system indefinitely and may generate vivid images of the
traumatic experience, terrifying thoughts, feelings, body
sensations, sounds and smells
• Schore (1994, 1996,2003) reported that children who
experience chronic traumatic stress have adversely affected
right brain development due to neuronal damage and atrophy
• As a result they do not deal well with stress, have difficulty
understanding emotion expressed by others and thus have
problems with empathy
7
Exposure of the developing brain
to stress hormones exerts
consequences by:
– Affecting gene expression
– Myelination
– Neural morphology
– Neuroegenesis
– synpatogenesis
8
9
Areas of the brain said to be
affected by early stress
•
•
•
•
•
Corpus callosum
Hippocampus
Prefrontal cortex
Visual cortex
Auditory cortex
10
11
Later effects of early stress/trauma
– when recalling trauma the left frontal cortex shuts
down (especially Broca’s area, the centre of
speech and language)
– but the right hemisphere associated with
emotional states and autonomic arousal,
especially the amygdala (centre for detecting
threat) increases activity
– the frontal lobes become impaired and so the
individual has trouble thinking and speaking’
12
Need for alternative approaches in
treatment
• As the effects of trauma are often stored in
body memories that verbal therapies cannot
release, we need therapies that depend on
action rather than verbalisation’ (van der Kolk,
2003)
• ‘Traumatic experience is largely affective and
somatic and so effective treatment must also
address the body’ (Solomon & Heide, 2005)
13
‘There is nothing more practical than a
good theory’ (attributed to Kurt Lewin
•
A neuroscientific account of human behaviour
requires consideration of four levels of analysis:
•
•
•
•
•
aetiology - concerned with the influence of genetic and
environmental factors causing psychopathology
brain mechanisms - concerned with the effects of aetiological
factors on the development of the brain (how it is sculpted in its
early formation) and its subsequent functioning
neuropsychology - concerned with the brain-based mechanisms
that generate human behaviour
Symptom level analysis - concerned with the clinical phenomena
thought to characterise psychopathology
(from Pennington, 2002)
14
Can we broadly apply this
framework in sex offender
work?
• Sexual abuse occurs as a consequence of a network
of causal factors:
– biological (genetic variations, abuse history?)
– core neuropsychological systems
– ecological (social and cultural environment, personal
circumstances, physical environment)
– clinical factors
• All four of these levels should be mutually
constraining, hence consistent with each other
15
Biological effects: Gender differences in
sexual offending?
• From Kafka (2008) Adult males have 6 to 10 times amount of
active testosterone compared to females
• Physiological effects on the limbic system, e.g., amygdala,
parts of the thalamic, hypothalamic nuclei as identified in
fMRI studies
• Hypothalamus/ amygdala (have the highest density of
androgen receptors - larger in males
• These brain areas associated with motivation, arousal,
performance
• According to Kafka it is likely that testosterone’s physiological
effects play an important role in producing the predominance
of sexual assaults in males compared to females due to its
effects in these areas
16
Brain mechanisms: Recent
scanning studies
• Cantor et al. (2007) compared 65 paedophilic sex
offenders with 62 non-sex offenders
• The study found cerebral white matter deficiencies in
the paedophilic sample
• White matter is composed of bundles of myelinated
nerve cells which connect various gray matter areas
(which primarily contains neural cell bodies) to each
other
17
Brain mechanisms: Recent
scanning studies
• These deficiencies were specifically related to two major fibre bundles
– The superior frontal-occipital fascuculus
– The right arcuate fascilus
• Cantor’s argument is that the these two bundles connect the
cortical regions that respond to sexual cues
– Therefore the cortical regions act as a network for recognizing sexually
relevant stimuli
– Paedophilia results from a partial disconnection from this network
18
19
20
An Integrated Theory of Sexual Offending –
containing a strong neurobiological component
Ward & Beech (2006)
21
From Pennington: Three interlocking
neuropsychological functions
• Three interlocking neuropsychological systems.
• These systems are components of human agency as
reflected in goal directed actions (practical reasoning)
– Motivation and emotional system
– perception and memory system
– action selection and control system
23
Motivational-Emotional system
Associated with orbitofrontal, some limbic (amygdala), and brainstem (locus ceruleus, ventral tegmental
areas, substantial nigra, raphe nuclues) brain structures
24
Problems in the Motivation and
Emotion System
• Problems in an individual’s genetic inheritance, or negative
individual experiences, may lead to defects in the
motivational/emotional system
• would include feelings of:
•
•
•
•
Inadequacy
Loneliness
Lack of empathy
Hostility
• Maps broadly onto the kinds of problems that have been described
as stable dynamic risk factors
 Thornton (2002) Domain 3 - social and emotional functioning
 Intimacy deficits - Hanson & Harris’ STABLE 2007
25
Action Selection and Control System
Associated with the frontal cortex, the basal ganglia, and parts of the thalamus
26
Problems in Action Selection and
Control System
• Help to plan, implement, and evaluate action plan
o and to control behaviour in service of higher-level goals
o Essential for evaluation of goals (and associated primary goods or
values)
• Problems that might arise from malfunctions in action control and
selection system essentially span self-regulation problems such as
– Impulsivity
– failure to inhibit negative emotions
– inability to adjust plans to changing circumstances and poor problem
solving skills.
• Maps broadly onto the kinds of problems that have been described
as stable dynamic risk factors
– Self-management problems (Domain 4) (Thornton, 2002)
– Sexual self-regulation and general self-regulation - STABLE 2007
27
Perception and Memory System
Associated primarily with the hippocampal formation and the posterior
neocortex
28
Problems in the Perception and
Memory System
• Major functions of this system are to:
– Process incoming sensory information
– To construct representations of objects and events, and make them
available to the Motivational/emotional and the Action selection and
control systems
– Can be seen to contain representations or knowledge of world, others
and self.
• Problems in perceptual and memory system can lead to:
– maladaptive beliefs
– attitudes
– dysfunctional interpretations of interpersonal encounters
• These problems can be seen as stable dynamic risk factors
– Attitudes supportive of sexual assault (STABLE 2000)
– Distorted attitudes (Thornton, 2002) (cognitive distortions)
29
Neurobiology of dynamic risk
domains
• Domain 2 problems - Perception and memory system
difficulties
• Domain 3 problems – Motivation and Emotional system
problems
• Domain 4 problems - Action Selection and control system
difficulties
• Negative interactions between all three systems thoughts,
feelings, lack of impulse control/ emotional dysregulation
leads to Domain 1: deviant sexual interest problems – as
arousal per se. is a purely a mechanical function
30
Clinical Phenomena
• Deficits in neuropsychological functioning interact with
individuals’ current ecology or physical environment
(proximal dimension)
• Cause the emergence of four groups of symptoms or
clinical phenomena that are directly associated with
sexual offending.
• These clinical phenomena can be usefully viewed as
proper temporal acute risk factors
–
–
–
–
Deviant arousal
Cognitive distortions
Social difficulties
Emotional/behavioural dysregulation
31
So what are the acute dynamic risk
factors in ACUTE 2007
• These are risk factors of short or unstable temporal duration that can
change rapidly, generally as a result of environmental or intra-personal
conditions
• In Hanson ad Harris (2007) ACUTE 2007 these are:
–
–
–
–
–
–
–
Victim Access
Hostility
Sexual Pre-occupation
Rejection of Supervision
Emotional Collapse
Collapse of Social Supports
Substance Abuse
• These would be better viewed as triggering risk factors
32
Need for alternative approaches
• ‘As the effects of trauma are often stored in
body memories that verbal therapies cannot
release, we need therapies that depend on
action rather than verbalisation’ (van der Kolk,
2003)
• ‘Traumatic experience is largely affective and
somatic and so effective treatment must also
address the body’ (Solomon & Heide, 2005)
33
Other approaches to therapy
•
•
•
•
•
•
•
Compassionate mind training/self-compassion
Neuro Linguistic Programming (NLP)
Sensorimotor psychotherapy
Somatic/movement therapies
EMDR
Mindfulness
Expressive arts therapies – art, music, drama
34
Self-compassion approaches to
treatment
• Based on work of Kristin Neff (University of Texas)
• ‘the extending of compassion to the self for one’s failings and
inadequacies and during experiences of suffering’
• Three components:
– Mindfulness – seeing things as they really are and in
perspective, accepting what the situation is without
minimising or exaggerating
– Kindness – treating the self with care and understanding
rather than harsh self-judgment
– Common humanity – seeing one’s own experience as part
of the larger human experience rather than separate and
isolating
35
Self-compassion contd.
• ‘self-compassion is different to self-pity as it does not
involve being self-centred or exaggerating personal
suffering’
• ‘self-compassion provides self-clarity, seeing things
as they really are, which can help to identify problem
ways of behaving (seeing yourself as you are)
• ‘self-compassion creates a supportive emotional
environment for change as it provides the safety to
admit the truth about oneself and this can in turn
provide the motivation for change’
36
Self-compassion contd.
• Studies have shown that self-compassion is
strongly linked to well-being
• This includes:
– greater happiness
– optimism
– sense of connectedness (belonging)
– resilient coping
• Therefore links to the ‘Good Lives’ approach
to treatment
37
How might self-compassion be helpful
for sex offenders?
• Can help them face up to what they have done and
take responsibility for their behaviour – denial, shame,
guilt
• Can help them tolerate difficulties and problems
• Can motivate them to change – by making them feel
worthwhile
• Can increase their sense of self-worth - which can help
lessen any urge to sabotage progress as a form of selfpunishment – ‘I don’t deserve anything good – I need
to be punished’
38
Helping overcoming treatment
barriers
• Many offenders do not feel positive about
themselves
• They may feel they do not deserve anything
positive and so reject or sabotage progress
• Until they can feel compassion towards
themselves they may be unable to fully face up to
what they have done
• Until they can empathise with themselves they
are unable to empathise with others, i.e., if you
don’t care about yourself you are unlikely to care
about others
39
Why self-compassion as opposed to working
on self-esteem
• Self-compassion is associated with greater emotional
resilience in stressful or negative situations, taking more
personal responsibility for one’s role in negative life events,
greater stability in feelings of self-worth and fewer downward
social comparisons, being less self-centred and less angry
• Self-esteem involves needing to see yourself as better than
others i.e. you put others down in order to feel better about
yourself
• The pursuit of high self-esteem may also be linked to
downward social comparisons and prejudice, defensive anger,
self-centredness and distorted ideas about oneself
40
Compassionate Mind Training
• Developed by Paul Gilbert (Uni. of Derby)
• Client uses a series of meditations and is helped
to develop a ‘compassionate image’ which s/he
then imagines focused on the self
• This helps to self-soothe, calm arousal and
provide the client with feelings of support and
nurturing – something they probably did not
receive as a child
• Works at a neurobiological level to stimulate key
areas of the brain
• Motivational-emotional system
41
Eye Movement Desensitisaton and
Reprocessing (EMDR)
• Controversial method developed by Francine Shapiro in 1989
• Use of alternating, rhythmic stimuli whilst client focuses on
traumatic image
• Strong anectdotal evidence but controlled studies variable
• Critics believe it is a form of exposure and that there is more
evidence for the use of exposure – however not all clients can
cope with exposure treatment
• Despite this, now included in NICE guidelines regarding
effective treatments for PTSD
42
EMDR contd.
• Levin, Lazrove & van der Kolk (1999)
• Used SPECT scans before and after EMDR sessions
with 6 subjects over 3 sessions
• Reported an increase in bilateral activity in the
anterior cingulate cortex (modulates the limbic
system and helps distinguish real from perceived
threat)
• Increased ACC indicates decreased hypervigilance
• Also increased pre-frontal lobe metabolism which
suggests greater ability to make sense of incoming
sensory stimulation
43
Mindfulness
• Defined as "a kind of nonelaborative, nonjudgmental, present-centered
awareness in which each thought, feeling, or sensation that arises in the
attentional field is acknowledged and accepted as it is". (Bishopp et al.,
2004)
• Two-component operational definition
– self-regulation of attention so that it is maintained on immediate experience, thereby
allowing for increased recognition of mental events in the present moment
– adopting a particular orientation toward one’s experiences in the present moment, an
orientation that is characterized by curiosity, openness, and acceptance.
• Recent research supports promising mindfulness-based therapies for a
number of medical and psychiatric conditions, chronic pain, depression
and substance abuse, recurrent suicidal behavior
44
45
Conclusions regarding other
approaches to therapy
• ‘Top-down processing i.e. CBT – use cognitive strategies to manage
or inhibit problematic thoughts, feelings and behaviours – uses the
neocortex and does not process episodic memories or resolve
physiological hyperarousal
• Even with years of therapy, immediate responses to triggering
stimuli tend to be physiological rather than logical
• Biologically informed therapy uses ‘bottom-up’ processing which
focuses on what is going on in the body
• This helps clients connect with their bodies and feelings, facilitates
learning to tolerate intense feelings and to release emotion
appropriately (Solomon & Heide, 2005)
46
References
•
•
•
•
•
Pennington, B. F. (2002). The development of psychopathology: nature and
nurture. New York: Guilford Press.
Siegel, D.J. The Mindful Brain. London: Norton
Solomon, E.P. & Heide, K.M. (2005). The biology of trauma: Implications for
treatment. Journal of Interpersonal Violence, 20, 51-60.
Teicher, M.H. (2007). Childhood abuse, brain development and impulsivity. Paper
presented at the MASOC/MATSA Joint Conference, Marlborough, MA, available
from: www.mclean.harvard.edu/pdf/research/clinicalunit/dbrp/mteichertalks/MASOC_MATSA_meeting.pdf
Tucker, D.M. (2007). Mind from body: Experience from neural structure.
Oxford: OUP.
• Van der Kolk, B. (2003). The neurobiology of childhood trauma and abuse.
Child and Adolescent Psychiatric Clinics of North America, 12, 293-317.
47
Other generally useful references
• Cozolino. L. (2006). The neuroscience of human relationships:
Attachment and the social brain. London: Norton.
• Hodgins, S., Viding, E., & Plodowski, A.. (2009), The
neurobiological basis of violence: Science and rehabilitation.
Oxford: OUP
• Romer, D. & Walker, E.F. (Eds.) (2007). Adolescent
psychopathology and the developing brain. Oxford: OUP
48