Assessment, Determining Treatment Type Level of social functioning There are many different capability levels within the community and within the population diagnosed with developmental disabilities Some benefit greatly from more verbal strategies and cognitive behavioral strategies, some do not. The question to ask is: “Is this person’s freedom of movement and access to the community limited solely because of the sexual behavior?” The answer for the group participating and benefitting from a therapy group, the answer was a resounding, YES. For others, that answer was…even if the sexual behavior was changed, this person would still need support and, therefore, supervision in the community and/or while living in his/her home So…if the person was limited only because of his/her sexual behavior, the authors chose to treat actively…if there were other limitations, the authors chose to do something else entirely Some Key Concepts: 1. 2. 3. 4. 5. 6. 7. Even if you have disabilities that severely impact on your freedom of movement, you still need the freedom to get all your needs met. Sexual offenses done against people with disabilities are serious crimes, even if the offender has similar disabilities. Agencies that serve people with disabilities cannot choose whom amongst that population they will serve. People with significant disabilities have a right to treatment tailored to their needs and that will, in the end, enhance the quality of their lives. Just because the work is hard, doesn’t mean you don’t do it. It’s ok to provide different service to different people, it’s called “individualized treatment”. Denying that difference makes a difference makes it impossible to provide “individualized treatment”. It is unfair to say that it’s unfair to provide one kind of treatment for those with greater abilities and another kind for those with greater disabilities. Political correctness can’t be the guiding force in determining effective treatment. The only question that an ethical practitioner has to answer to justify a treatment approach is, “Is the person’s quality of life greater after we’ve worked together than it was before our work began?” If the answer is any form of “Yes,” then ethical programming has occurred. So…how do you proceed with treatment…what are the goals? Reduce the likelihood of future sexual offense 2. Help the person devise ways to meet affection and intimacy needs in appropriate ways 3. Increase their overall access to preferred activities 1. Primary reasons for referral for treatment for those diagnosed with profound disabilities: They are sexually touching another person with a disability 2. They are masturbating at inappropriate times and places 3. They engage in behaviors that make them vulnerable to sexual assault For each, we need to make sure that the appropriate supports are in place. 1. Creating appropriate staff support: We need to train staff A crime against someone with a disability is still a crime even if the offender is also disabled The greater a person’s disability, the more likely it is that they will be abused The group that is second most likely to offend against a person with a disability is another person with a disability (the most likely to offend is a care provider) People have a right to have a safe working and living environment Offenders have a right to appropriate consequences and treatment that makes sense Law and Responsibility: 1. 2. 3. 4. If someone engages in the same behavior over and over again, they get skilled at it and they know what they are doing. The may not understand that it’s wrong and that they shouldn’t do it, that’s not the same as knowing what they are doing A crime is committed when a law is broken. A woman who is raped is still raped even if the person who did it is found not competent to stand trial. The crime is the act—it is independent of the person who did it. A loaf of bread is still stolen even if the person who took it has starving children to feed. Not acting to protect people with disabilities from ALL abusers is a mammoth lack of responsibility. Staff have got to care about creating a safe environment for a person with a disability to live in. If the staff don’t take the behavior seriously, then abuse will continue. In fact in one institution, they set a goal for the reduction of the assaultive behavior. They wanted it to get down to one rape per month! Victims of sexual assault, no matter their level of ability, are always traumatized by the assault. So many times we have heard it said, “Yeah, she was raped last Monday but it doesn’t seem to have affected her” or “He has a horrible abuse history, but you would never know it from his behavior.” The speakers are assuming, though they are not saying it directly, that the person with the disability is “too dumb to notice” that they’ve been victimized. Squeaky wheel: There are example after example of situations where a person with a disability is told that they are “fine”, that nothing is wrong, to ignore “teasing” or bullying and it will go away. The problem is that without confirming that there is no pain or bullying, the staff member may be “sentencing” this person to this situation…the person learns that they are not worthy of protection and that the staff don’t care about their pain Hurt happens, trauma follows Appropriate staff response comes with staff care enough to do the job of risk reduction, risk management, and ongoing supervision Staff allegiance needs to start with the victim and then to the victimizer. To support BOTH, the VICTIM must come first. “But he’s such a sweet guy….” Sweet guys rape, good staff know that. Risk reduction: By placing someone with a history of sexually offending, you have increased the risk of sexual assault for everyone in their environment. It is imperative that work be done to ensure that those others in the environment are protected (this is independent of the level of ability of the offender). More than that, the agency needs documentation to show what steps have been taken to mitigate risk. What are some strategies for this? Risk Reduction…Supervision Staff supervision needs to be 24/7, the sexual offender must be supervised at all times. All steps MUST be taken to assure that they do not gain access to a potential victim Staff need to be aware of: Potential victims Where assaults might happen in an environment When staffing levels are low or lacking …AND THEN FIX THE ISSUES PROACTIVELY This means that, working with the therapist, they need to design the environment so that it is unwelcoming to offending behavior This means that the sexual offender may need line of sight or side by side supervision at all times Staff have the RIGHT to have “supervision” spelled out clearly Supervision also means providing extra caution and concern for those who already have been victimized by this person or by those who might be. Knowing where people who could be targets are in relation to the client with concerning behavior should become standard practice. Risk Reduction: Environmental Changes The person may need their own bathroom and private areas The person may NEED an alarmed door and window They may need a baby monitor in their room They may need to be seated away from potential victims They may need their own, single chair in a living room They may need a staff member assigned at all times to be in the room with them and line of sight Overnight awake staff is MANDATORY! Risk Reduction: abuse prevention All people, regardless of disability can learn to say no to unwanted touch Persons with developmental disabilities and staff members need to learn appropriate boundaries and the ethics of touch to learn when it is appropriate to say no and what unwanted touch is Prevention isn’t enough! All people have needs for affection and intimacy, simply preventing unwanted touch or sexual offending does not meet the needs for affection and intimacy…so, what do we know about not meeting the needs a former behavior served? But…how? Individuals with significant disabilities would never be able to pass any kind of assessment regarding informed consent. True, but to end there is to take the easy way out of the dilemma Intimacy vs. Sexual Expression The drive and need for intimacy is greater than the drive and need for sex Research shows that people can go for years without sex without suffering any mental health concerns, but that people can only go for days without intimacy before they begin to experience depression and isolation along with a feeling of disconnectedness. The word intimacy here is in reference to touch, a sense of closeness, feeling embraced and other forms of social interactions that occur with friends and family and are decidedly not sexual. Our goal is for persons with significant disabilities to experience intimacy…here is the problem, we do not believe that it is appropriate for staff to meet intimacy needs. Some ideas to try: Touch needs: Prolonged shampoos Electric blanket wrap Dogs, cats, and rabbits Massage (professional, NEVER STAFF) Sensual needs: Aroma therapy Taste…spices, different foods Sounds…music, birds, etc. Why not just teach masturbation? We never teach masturbation…either the person has the skill or they do not. If they are masturbating in the wrong place or at the wrong time, we teach the appropriate place and time The drive and need for intimacy is greater than the drive and need for sex…masturbation isn’t enough, intimacy needs are not met through masturbation Human beings are complex, so are our needs And a reminder that sexual “oddness” is not just seen in those with developmental disabilities, nor in only those with mental illness, but everywhere…for your consideration…please discuss.