Transcript No Slide Title

Remaking Relapse Prevention
“Determinants of Relapse”
(Marlatt & Gordon, 1980)
New type of cognitive-behavioral intervention
Relapse prevention
Relapse prevention
Maintaining change in addicts
Ceased
Through other interventions
Relapse Rates for Addictions
First 12 months after cessation
80%
First 3 months
66%
(Hunt et al., 1971)
Negative emotional states
Interpersonal conflict
Social pressure
71% of all relapses
(drinkers, smokers, heroin addicts,
compulsive gamblers, and over eaters)
(Cummings et al, 1980)
Deviant Cycle
Life Event
Remorse,
Guilt, or Fear
Offense
Negative Affect
Thinking Errors
Grooming
or Force
Seemingly
Unimportant
Decisions (SUDS)
High Risk
Situations
Planning
Passive/Active
Target Selection
Developed for

Offenders motivated to change

Already ceased offending

Offended through “seemingly unimportant
decisions”
Not Developed For

Psychopaths

Child molesters who want to continue
“An important precondition for applying RP
interventions is that the offender be
motivated to stop offending.”
(George & Marlatt, 1980, p. 16)
In the Beginning

“the confidence and optimism we feel . . .
are quite strong . . .

“our confidence . . . is without empirical
support”
(Gordon & Marlatt, p. 28)
Why Was RP Adopted So Readily?
No other game in town
Northwest Treatment Associates
Seattle, WA
Gene Able & associates
NY/Atlanta
What is RP today?
“Relapse Prevention”
Has little meaning
“In the past 15 years, those words have
served as an umbrella under which a huge
variety of clinical interventions that had
little or nothing to do with the original
notions of RP could be found.”
(Laws, 2000, 0. 16)
Nationwide Survey
RP
Primary

Community
18%

Residential
25%
Includes
RP
97.9%
93.4%
(McGrath et al., 2002)
Cognitive Behavioral Treatment
Empathy
 Assertiveness
 Social skills
 Healthy sexuality
 Intimacy training
 Cognitive distortions
 Cognitive skills
 Relapse Prevention


“Relapse prevention “performed a deep
alchemy through which clinicians could
look at rapidly declining survival curves
and see mission, not despair.”
(Hanson, 2000, p. 36)
Instilling Knowledge of RP
Satisfactory offense chains
Initial testing
39%
3 repetitions
100%
(Marques et al., 1989)
Test of Basic RP Concepts
Initial testing
34%
3rd testing
100%
(Marques et al., 1989)
Sex Offender Treatment and Evaluation Project
(Marques, 1999)
Tx
Completed
Sex
Reoffense
Violent
Reoffense
Tx Drop
Outs
Controls
Volunteers
Controls
NonVolun
N = 138
N = 34
N = 184
N = 185
13
17.7
12.5
15.1
8.7
17.7
10.9
10.3
Was SOTEP a Test of RP?
 Sex
education
 Human sexuality
 Relaxation training
 Stress & anger management
 Social skills
 Substance abuse
 Deviant arousal
 RP
SOTEP
Chronic offenders
Mastered RP model
Lower recidivism rates
All offenders
No relationship
Mastering RP & recidivism
RP & Low Risk Offenders
SOTEP
Mastering RP
No lowered recidivism
No cycle?
Why Did SOTEP Fail?





Failure to motivate offenders
Lack of challenge of offenders
Too little focus on affective factors
Lack of practice in coping skills
Lack of a strong conditional release component
Instilling Knowledge of RP
Community based tx in England
27%
RP Too Complicated
 Abstinence
violation effect
 Success expectancy
 Erroneous attributions
 Apparently irrelevant decisions
 Negative emotional state
 Problem of immediate gratification
 Adaptive coping response
 Increased probability of relapse
RP Can Be Taught
 Awareness
of high-risk thoughts
 Willingness to admit planning
 Recognition of high risk factors
 Knowledge of motivation for offending
 Ability to think of coping strategies
 Ability to tell others when at risk
Exposure to RP greater skills
(Mann, 1996)
Summary

RP dominant tx strategy for 15 years

Rarely as a solo program

Hard to teach

When mastered, ability to think of coping
strategies and tell others risk level
Losel & Schmucker
2005
Treated
N = 9,512
Untreated
N = 12,669
All programs
Sexual
11.1%
16.8%
General
27.9%
39.2%
Negative Results
Kenworthy, Adams, Brooks-Gordon &
Fenton, 2004
Rice and Harris, 2003
Does Tx Work Long Term?
12 Year Follow-Up
Treated
Untreated
(403)
(321)
Sexual
Violent
General
21.1%
21.8
42.9%
44.5%
56.6%
60.4%
(Hanson et al., 2004)
Updated Relapse Prevention
Deviant Cycle
Life Event
Remorse,
Guilt, or Fear
Offense
Negative Affect
Thinking Errors
Grooming
or Force
Seemingly
Unimportant
Decisions (SUDS)
High Risk
Situations
Planning
Passive/Active
Target Selection
Self Regulation Model of Relapse Prevention
Life Event
Sometimes
Desire for
Offensive Sex
(Ward & Hudson, 1998)
Self Regulation Model of Relapse Prevention
Desire for
Offensive Sex
Avoidance
Goals
Approach
Goals
(Ward & Hudson, 1998)
Self Regulation Model of Relapse Prevention
Avoidant
Passive
Active
Approach
Automatic
Explicit
(Ward & Hudson, 1998)
Type of Offense Pathway: Roger





Unemployed
Bar from 12 to 3 pm
Left drunk
Boarded a train as “knew girls would be
there”
Goals: get one to perform oral sex
Type of Offense Pathway: Roger
Sat behind two 13-year-olds
Touched their hair and masturbated
Tapped one on shoulder
They got up and left
Got off train, saw a 13-year-old
Began masturbating
Type of Offense Pathway: Roger





Walked up to her with penis out of pants
Wanted her to perform oral sex
She called out and other girls joined her
Bus arrived and they left
They reported to bus driver
Type of Offense Pathway: Roger
“I just do things for no reason.”
“I wish I could put into words how I feel, and
understand what it is all about.”
Type of Offense Pathway: Roger

Knew by heart the routes home of children
from local schools and holidays and breaks

It was “familiar territory” so never had to plan

Says “thousands” of victims

Convicted 13 times
Type of Offense Pathway: Roger

Says he felt children enjoyed the experience

“I don’t hurt anyone and people quite like
what I do. I never carry out my fantasies
about rape and hurting people in real life.”
Roger: What Kind of Offender?
Approach Automatic
What Kind of Treatment?
Type of Offense Pathway: Dave






40 year-old
Confident and outgoing
Worked abroad in a program to help teen
prostitutes
Talked to pimps
They made a “powerful case”
Felt his values had “become contaminated”
Type of Offense Pathway: Dave
“Some of the younger girls I was trying to
help said that things about the life were
good. Intellectually I knew that that was
about comparisons with the life they had
before, extreme poverty and so on, but at
another level I got interested – although I
never did anything wrong to them.”
What Type of Offender: Dave




In past had baby-sat for 11-year-old
Went in bedroom aroused and watched
child sleep
Told wife
Agreed never to babysit again
Type of Offense Pathway: Dave

I talked to my wife about the babysitting
experience before we had the children.
That was good, but then I sort of laid the
responsibility for stopping it happening
again on her. I did that again after our
daughter told her what I’d been doing.”
Type of Offense Pathway: Dave





Family living in an open-plan home in hot
climate
Kids often undressed
Felt 10-year-old daughter was seductive
Knew his arousal was wrong
Tried to avoid situations where he might
abuse her
Type of Offense Pathway: Dave




Refused to share a tent with her on
camping trip
Other times he fondled her genitals
Once persuaded her to straddle him
Told himself knew what was happening
and agreed
Type of Offense Pathway: Dave



When wife gone, got into daughter’s bed
to have intercourse
Realized what he was doing and stopped
Shaken that he almost raped her
Type of Offense Pathway: Dave

“I thought that carrying on with my work
would help me get my head straight –
instead it was just making it worse.”
Type of Offense Pathway: Dave
“I kept away from my daughter – wouldn’t
take any interest in her. She wondered
what was wrong with me – my wife says
that made her more likely to want affection
from me. Then when she came to me I
misread what she wanted, because my
thinking was getting so messed up.”
Dave: What Kind of Offender?
Avoidant Active
What Kind of Treatment?
Type of Offense Pathway: Joe






40-year-old
6 cts against one boy, now 19
Over 8 years
Fondling, oral sex, anal intercourse
Working as handyman at boy’s house
Boy began to hang around him
Type of Offense Pathway: Joe






Urinated in bushes and boy saw it
Boy watching excited him
Asked boy to touch his penis
Boy compliant
Escalated to anal intercourse
Boy told him he didn’t want to do these things
Type of Offense Pathway: Joe





Told boy it was normal
Told him no one would believe him
Told boy, why had he done it if didn’t want
to
Told boy if reported, they would blame him
Told boy that he (the boy) was gay
“You’re just a little queer! Why don’t you
accept that?”
a
Type of Offense Pathway: Joe

2 previous convictions
Type of Offense Pathway: Joe
Previous Treatment
“You’re got to go along to get along. If I was ever going
to get out of there, I realized that I was going to have
to learn to say what they wanted to hear.”
Psychologist: Did well and was able to “freely share his
experiences and mistakes with other group members
and to take responsibility for his actions.”
Type of Offense Pathway: Joe
“showing them what real life was like”
“You need to know how to get that feeling of
being in charge – the world is a frightening
place”
“Of course, I took my ‘fee’”
Joe: What Kind of Offender?
Approach Explicit
What Kind of Treatment?
Type of Offense Pathway: Ben





25-year-old
Police called to residence – found father of
a 5-year-old holding Ben in custody
Ben was babysitting
Returned to find him in bed with son
Boy crying; told parents Ben had “touched
my thing and sucked on it.”
Type of Offense Pathway: Ben

3 arrests at ages 15, 22 and 23: all
victims boys under 10

No other criminal history
Type of Offense Pathway: Ben

1st offense: met 6-year-old when he was
coming home from school. Bought him ice
cream, took him to a park, pulled down his
pants and fellated him

After graduating from university, picked up
a boy, took him for a ride, drove to a park,
fondled him and fellated him
Type of Offense Pathway: Ben
Uncomfortable around adults his age
“They seemed so much more grown up than
I was.” “I felt awkward, like I couldn’t get
one foot in front of the other.”

Children: “They weren’t trying to live up to
some social standard.” “I envied them
because they seemed so free, so at ease
in their world.”
Type of Offense Pathway: Ben
“I will admit that I especially liked looking at
the boys. They were so cute, bright eyed,
smooth skin. It sounds silly, but I wished
that I could look like that, rather than a
hulky, almost adult male.”
“It must have been then that I began to think
about them sexually.”
Type of Offense Pathway: Ben
“When I jerked off, I tried to fantasize about
girls my age in my classes, but it didn’t
work. When I thought about kids, I felt
guilty, but I got really aroused and I could
ejaculate. Although I didn’t really want
them to be, the fantasies were about
feeling these kids up and sucking their
dicks. The more I did it, the easier it got.”
Type of Offense Pathway: Ben
“When I saw that kid in 1989, I don’t know, I
guess I just felt that I had to do it. I
conned him and I took him to the park and
went down on him. I felt like shit after
that.”
Type of Offense Pathway: Ben

Cruised while at university, but didn’t pick
up any kids. Afraid of getting kicked out.

“After I graduated from university and
couldn’t find a job, I felt worthless. So I
started cruising again.” “This time I was
afraid something would happen, and it
did.”
Type of Offense Pathway: Ben

Felt guilty. Boy couldn’t identify him.

“I should have said, ‘Hey! I did it!’ but I
didn’t.”
Type of Offense Pathway: Ben
Last offense, asked boy, “Do you want to
learn about sex?”
“It seemed to me that he was fine with it until
his old man burst into the room.”
Type of Offense Pathway: Ben

Still masturbating to fantasies. “I can’t
seem to stop it.”

Response to first arrest: “I just wanted to
forget about it.”
Ben: What Kind of Offender?
Avoidant Passive
What Kind of Treatment?
Implications for Treatment
Factors in Offending
Avoidant Passive






Lack of skills
Under-regulated
Deviant Arousal Patterns
Problems with Intimacy, Etc.
Cognitive Distortions
Dysfunctional Schemas
Factors in Offending
Avoidant Active



Misinformation
Misguided strategies
Lack of effective skills




Deviant arousal
Problems with intimacy
Cognitive Distortions
Dysfunctional Schemas
Factors in Offending
Approach Automatic








Automatic Scripts
Lack of Monitoring
Under Regulated
Deviant Arousal
Loneliness, etc.
Cognitive Distortions
Dysfunctional Schemas
Psychopathy
Factors in Offending
Approach Explicit

Cognitive Distortions
Dysfunctional Schemas
Deviant Arousal
Psychopathy
Loneliness, etc.

NOT a Regulation Problem




Good Lives Model

RP
Avoidant

Good lives model
Approach
Primary Goods
People seek primary goods
Primary Goods
Experiences, states of mind, activities
Sought for their own sake
Increase psychological well-being
Sexual Offending
Attempts to pursue primary human goods
Socially unacceptable
Personally frustrating
What Are Primary Goods
 Relatedness
 Health
 Autonomy
 Creativity
 Knowledge
Tender Minded Theory
People are good
Bad acts are an attempt to meet same
needs as everybody else
Theoretical Position
“It is true that we did not cite any study
applying the ideas of Deci and Ryan
[human needs and self-determination] to
an offender population – to our knowledge
there are no such studies yet.”
(Ward & Stewart, 2003, p. 222)
Theoretical Position
“. . .there is little or no evidence for the
assessment and treatment aspects of the
theory other than the rationally based
reasons outlined above. This weakness
reveals that the theory lacks empirical
adequacy.”
(Ward et al., 2006, p. 311)
Deci & Ryan (2000)
Nonoffenders
Autonomy, competence & relatedness
Correlated with
Indices of well-being
(Negatively correlated with anxiety and
depression; positively correlated with selfesteem)
Innate needs
Correlated with
Noncriminogenic needs
( Bonta and Andrews, 2003)
“I plain and simple needed to get some
good, hot, kinky sex but resented having
to rely on the generosity of women to hit
on their pussies. . . My days of begging . .
. Were over.”
(Athens, 1997, p. 10)
Applying the Good Lives Model
What goods are associated with offending?
Pursuit of emotional equilibrium
Intimacy
Personal control
Grievance
Sexual pleasure (goods of health & body)
Play (to get a thrill)
What Prevents Meeting These
Appropriately?
Socially isolated
Lack skills for relationships
Overly aggressive when mood low
Identifying Overarching Primary
Goods
Mechanically Inclined
“In this example, he might enroll in a night
course on practical mechanics
(knowledge), join a car club (relatedness),
and eventually train as a car mechanic
(mastery at work).”
(Ward et al., 2006, p. 308)
Identify Environment Needed
 Info
about opportunities for work
 Social supports
 Living arrangements
 Culture of the community
People are What They Do
To forge a more adaptive personal identity
Must live a better life
Rehabilitation Involves

Looking at past life

Developing a new good lives plan
Must Take into Account
 Offenders’
 Primary
Goods
 Relevant
 What
strengths
Environments
competencies & resources?
“The problem does not reside in the primary
human goods that underlie offending, but
in the way individuals seek these goods.”
(Ward et. Al, 2006, p. 307)
Secondary Goods
Ways primary goods are translated into
action
Primary goods:
work
Secondary goods: Training in computers
At Its Best

Loneliness:
Risk factor

How to build a life with social connection
At Its Worse

Takes sex out of sexual offending

Exercise, eat well, get a job – you’ll be fine
Assumptions
Lost Souls or Predators
Lost Souls Only Need Apply
Is All Offending from Frustration?
Psychopathic
Predators
Sadists

“I like to live on the edge. I like being
wanted by the police. I like being chased
by the police. When you live that kind of
life you really can’t stop to think. You
never think. You just do, do, do. If you
stop you won’t do it. I never stop to
analyze it.”
“I’d have to say I did get a high out of violent
behavior. I got – I got a high out of any
controlling and dominating situation. Any, any
situation that I was able to control – right? – I
got a high out of. I had like an adrenaline rush.
I felt powerful, in charge, where in a
consensual sexual relationship, sure orgasm
was achieved, ejaculation was achieved, and
then it’s over. But the feeling of power and
control lasts, it would last a lot longer. And it’s
something I knew that I could achieve at any
given point in time. All I, I knew what I had to
do. All I had to do was control somebody or
dominate, and that high was there.”