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 Negative Affect Offense Grooming or Force Thinking Errors Planning Passive/Active Seemingly Unimportant Decisions (SUDS) High Risk Situations 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)

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)

 Community  Residential

Nationwide Survey

RP Primary Includes RP 18% 97.9% 25% 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% 3 rd testing 100% (Marques et al., 1989)

Sex Offender Treatment and Evaluation Project (Marques, 1999)

Tx Com pleted Tx Drop Outs N = 138 N = 34 Controls Volunteers Controls NonVolun N = 184 N = 185 Sex Reoffense Violent Reoffense 13 8.7

17.7

17.7

12.5

10.9

15.1

10.3

Why Was RP Adopted So Readily?

No other game in town Northwest Treatment Associates Seattle, WA Gene Able & associates NY/Atlanta

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% 42.9% 56.6% 21.8

44.5% 60.4% (Hanson et al., 2004)

Updated Relapse Prevention

Deviant Cycle

Life Event Remorse, Guilt, or Fear Negative Affect Offense Grooming or Force Thinking Errors Planning Passive/Active Seemingly Unimportant Decisions (SUDS) High Risk Situations 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)

Treatment Components

Agenda

RP & Good Lives Minimal Arousal Conditioning Denial Role of Family Treatment

 A. “We weighed it up and made sure that each unit weighed a kilo and did a general purity test on it.

 Q. How do you do a general purity test?

 A. Well, we snorted a bunch of it.”

 “The Court: “Now you are entitled to a speedy and public trial by jury or by court. You know what a jury trial is?” Defendant: “Yes” Court: “What’s a jury trial?” Defendant: “A jury trial, twelve people find you guilty.” Court. Yeah that is about right.”

Court: “You were picked up on a new 245?” Defendant: “I don’t know if it was a 245, 645, 345. They picked me up on something, all right? Okay? Then when they also had me on that, he gave me a motherfucking charge for prostitution.” Counsel: “Don’t use language like that to the judge.” Defendant: Prostitution? What? Prostitution? What do you want me to say? They picked me up for prostitution.”

Police Report

 “I observed defendant driving without headlights on. Defendant’s vehicle was swaying from westbound curb lane to eastbound # 1. As defendant’s vehicle passed, I observed defendant with a large dog helping defendant drive (dog had front paws on steering wheel, possibly trying to save its own life.). Upon stopping defendant’s vehicle, defendant began yelling, ‘Fuck Skippy [the dog]. You really got me fucked this time.’ Skippy had no statement.”

Self Regulation Model of Relapse Prevention Avoidant Approach Passive Active 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

 1 st 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?

Good Lives Model

 RP  Good lives model Avoidant 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 self esteem)

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’ strengths  Primary Goods  Relevant Environments  What 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

 Loneliness:

At Its Best

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.”