Transcript Lemmings & Ostriches: Working with MR/DD Sex Offenders

Working with IDD Sex
Offenders
Michael Gavetti
Introduction
IDD Offenders are neither fish nor fowl:
Serious crimes, but often not competent to stand trial.
End up on locked long-term state institutions (with no SO
treatment available).
No specialized community programs, so they end up
locked up forever without having a trial.
Alternative is to release them without appropriate
supervision– agencies often refuse to accept them.
Some recipients commit offenses, but because they are
not prosecuted or institutionalized, the information about
their offenses is lost, omitted, deleted, or simply missing.
Means that there are many unidentified IDD offenders in
the community.
What are some differences in Tx for
different types of sex offenders?
Most adults are referred from the criminal justice system,
and are obligated to attend and participate in Tx as a
part of their probation/parole
(nonparticipation=incarceration).
Most adolescents are referred and treated within the MH
system (juvenile courts are often involved). They are
often referred to RTFs where attendance is mandatory,
but there is no way to enforce participation.
Many IDD adults never stand trial, and are overseen by
DMRS. They are often under no obligation to attend or
participate in treatment.
How are IDD offenders likely to
come to your attention?
Juvenile offenders aging out of the system, now
in need of adult services.
Families who had been coping with offending
behaviors on their own no longer able to support
their IDD SO children.
Changes in SO law/community attitudes may
mean that previously ignored offenses now
reported to the authorities.
Lawsuits pushing some offenders out of longterm treatment facilities.
Why don’t we know more about which
IDD recipients are sex offenders?
Data never tracked by state
No comprehensive information files for recipients
Direct care staff sometimes reluctant to document sexual
behaviors
Police reluctant to arrest recipients who have DMRS
services
Courts unwilling to prosecute cases that will not lead to
conviction (i.e., some recipients not competent for trial)
ISC’s reluctant to mention inappropriate sexual
behaviors in plans
Family/advocates attempt to soften/delete historical
information to limit bias
Information “lost” to facilitate referral/transition process
Even if ID’d, trouble getting recipients connected to
appropriate services
What barriers do SO Tx providers face
when working with IDD clients?
Nation-wide/ state-wide lack of knowledge about
how to treat sex offenders (including a lack of
research-based programs for working with sex
offenders)
Criminal justice system shortfalls for addressing
SO behaviors in IDD offenders
Most SO providers have less experience working
with IDD recipients than with non-IDD
populations (and no empirically-based
programming materials)
Funding (many IDD offenders are indigent)
What barriers do IDD providers face
when working with SO clients?
Lack of local sex offending treatment resources for the
IDD population
Lack of IDD service personnel with SO experience (at all
levels—management, clinical, direct care)
Lack of willingness to confront SO issues directly (e.g.,
conflict between traditional IDD values and SO treatment
recommendations)
Cultural reluctance to discuss sexual issues for IDD
populations
Fear of liability issues
What is DMRS?
Division of Mental Retardation Services
Located within the Tennessee Department of Finance and
Administration
(from the web page) DMRS is the state agency responsible for
providing services and supports to Tennesseans with mental
retardation.
DMRS provides services directly or through contracts with
community providers in a variety of settings. These settings range
from institutional care to individual supported living in the
community.
There are three long-term care facilities in the Division system:
Arlington Developmental Center in Arlington, Clover Bottom
Developmental Center in Nashville, and Greene Valley
Developmental Center in Greeneville.
Regional offices located in Memphis, Jackson, Nashville,
Chattanooga, Knoxville, Greeneville and Johnson City work with
community agencies to provide services.
How is DMRS useful to you?
Being enrolled in DMRS services gives the client
access to healthcare coverage, case
management, and other supports.
DMRS supported living agencies can provide
24/7/365 supervision (at 1:1 or 2:1 staffing
levels) for identified offenders.
Some DMRS provider agencies can provide
educational help and/or social skills training.
DMRS services represent a real alternative to
traditional criminal justice interventions.
West TN DMRS has a work group that can help
facilitate connection to specialized services
(SBRRC)
What are some complexities
to working within DMRS?
Educating the Circle of Support (COS)
Collaborating with the provider agency
Helping client families who may be in
denial
Assisting providers as they try to navigate
the HRC (Human Rights Committee) and
ISP (Individual Service Plan) processes
DMRS cultural concerns
Inertia of DMRS system is towards individual
choice and autonomy– providers are reluctant to
limit choice or restrict SO recipients
Providers sometimes tempted to compromise
structure in the face of family pressure
24/7 staffing, high employee turnover– high risk
for miscommunication between shifts
Significant limits to what can be “imposed” on
recipients without their permission
System is ISP driven
What type of structure should SO Tx
providers be facilitating/advocating?
Highly structured & consistent environment
Trained staff with clear communication systems
Integrated treatment services (both for SO and
non-SO issues)
Consistently enforced restrictions that maximize
both safety and appropriate choice
Close collaboration with other involved
institutions/programs (including DMRS)
What is the current
standard of care?
The TN SO Tx Board subscribes to a “lifetime supervision”
model.
Means that although sex offending can be treated, there
is no “cure” and the person will always have at least
some risk for re-offending.
Supervision requirements and treatment goals are driven
by client-specific factors, such as global risk for reoffense, progress in treatment, and type of offending
pattern.
As the person progresses in treatment, less supervision
is required in order to minimize re-offending risk.
What sort of SO Tx content should
be covered for IDD clients?
Same as for other adult offenders (TN SOTB curriculum)
Life history, including full disclosure of all sex offenses
(supported by polygraph, if possible).
Anger management (often a trigger).
Cognitive restructuring (to alter schema that support
offending)
Communication/Assertiveness (offending is a
maladaptive coping response for some offenders)
Relapse prevention
Sexual reconditioning (to alter deviant arousal patterns)
Victim impact/empathy
Clinical Treatment Differences
(Ability)
Literacy problems
Limited memory
Difficulties with abstract reasoning
Empathy and cognitive development (Kohlberg,
Piaget, Erikson, etc.)
Clinical Treatment Differences
(History)
Sometimes sheltered from consequences of
their actions
Sexual education deficits
Long histories of institutionalization
Few or no historical experiences with healthy
sexuality (often have little experience with
healthy adolescent dating)
Sometimes been taught to “play dumb” as a
defense
Clinical Treatment Differences
(Current lifestyle)
Limited social supports
Limitless unstructured free time
Limited finances
Social skills deficits
Naive perceptions of complex relationships
Generalized belief that all sexual behaviors are
bad (i.e., will get you in trouble or are “nasty”)
Limited opportunities for current healthy adult
sexual relationships
Clinical Treatment Differences
(Therapy)
Pace of sessions is slower
Duration of treatment is longer
Greater emphasis on repetition and psychoeducation
Progress occurs in smaller increments
Emotional work more basic (often starts with
emotional identification)
Multi-step interventions often impractical
Homework often difficult to implement
Real-life examples more effective than metaphor
or abstract imagining
How do you prepare an IDD
client for SO group treatment?
Explain environmental structure multiple times
(programmatic, therapeutic, criminal justice)
Ensure that restrictions have been approved by
HRC and added to ISP
Gather information in detailed SO history
(usually requires in-depth review of
documentation and involves multiple individual
sessions), and prep to discuss Hx in group
Create SO group introduction using the
offender’s own words (respectful language only)
ID the recipient’s offense pathway
Introduction Example
An example introduction from the Sex Offender Group
(taken verbatim from his own disclosures whenever
possible):
“My name is XXXXX. So far I have told about three victims.
My first victim was a 6-year-old girl that I knew from my old
neighborhood. I got close to her by helping her to fix her
bike, then I raped her when nobody was watching. My
second victim was a little white girl named YYYYYY. She
was in the bathroom at a public park. I touched her under
her clothes on the leg and between her legs. I stopped
when my sister came in and told me to stop. It was never
reported to the police. My third victim was a little darkskinned black girl named ZZZZZZZ. I raped her, but I’m not
ready yet to talk about the details of the offense. I am
always at risk to re-offend.”
Sex Offending Cycle
PseudoGuilt/shame
Trigger
Bad Feeling
Deviant Fantasy
Reliving thru
Fantasy
Cognitive
Distortions
Arousal
Planning
Escape
Setting up victim
OFFENSE
What is the Pathways model for
offense conceptualization?
Offenders do not all offend for the same reasons– there
are different cognitive processes and maladaptive coping
methods that lead to offense
These cognitive behavioral pathways to re-offense have
to do with how offenders self-regulate their behavior
(Ward, Hudson, & Keenan, 1998)
First distinction: avoidant (tries to avoid offending) vs.
approach (offending is pursued goal)
Model has evolved to include four sub-types of
offenders, defined by their offense regulation type.
What are the four subtypes of offenders
defined by the self-regulation model?
Avoidant passive (under-regulated)– want to
avoid offending, but lack coping mechanisms
Avoidant active (mis-regulated)– choose coping
methods that work poorly or short term
Approach automatic (under-regulated)– on
“autopilot”, move towards high-risk situations
and offend opportunistically
Approach explicit (intact regulation)– coping
methods support offending, move with planning
and intent
Does the Pathways model fit
for IDD offenders?
Yes, at least as far as we know (Keeling, Rose,
& Beech, 2007)
Similar distribution for IDD offenders across the
four groups as for non-IDD offenders
Distribution heavily favors Approach pathways
for both groups
ID of client-specific offender pathway has a reallife effect on both treatment emphasis and
environmental restrictions for IDD offenders.
How is assessment different
for IDD offenders?
Typically, no comprehensive summary of SO
history exists– often necessary to acquire and
sort through old documentation for bits and
pieces
Once rapport is established, can sometimes be
unusually forthcoming with unreported incidents
(NOTE– often requires a few vague facts to
“prime the pump”)
Mental status exam is critical
Memory problems are a real concern
Few standardized instruments for the population
What is the best way to
assess re-offense risk?
STATIC-99 is gaining popularity
The original sample included IDD offenders. The 2003 revised
Coding Rules specifically indicate that it can be used for
“Developmentally Delayed offenders” (pp. 6)
Problem– scoring depends entirely on charges/ convictions/
sanctions by the criminal justice system, and many IDD offenders
are not competent.
Solution– use incidents where the behavior was serious enough to
have been charged AND the client received some sort of sanction.
“If no sanction is applied to the offender, these offenses are not
counted. If the behavior is sufficiently intrusive that it would most
likely attract a criminal charge had the behavior occurred in the
community and the offender received some form of ‘in-house’
sanction, these offenses would count as offenses on the STATIC99.” (from the Institutionalized Offenders section of the 2003
STATIC-99 coding rules, pp. 7)
STATIC-99 (continued)
Ongoing unsanctioned offending behaviors
(exhibitionism, sexual phone calls, etc.) can make it hard
to ID an Index Offense
Incompetence to stand trial may mean serious offenses
(including child rape) may not have been officially
sanctioned (perhaps never even arrested or charged).
Offenses for which the recipient was not sanctioned or
punished may not be appropriate for inclusion in scoring.
Incomplete records mean that some serious offenses
may not even be listed as a part of a client’s history.
If anything, the STATIC-99 is likely to under-predict reoffense risk for this population.
What is the best way to assess
progress in treatment?
Treatment Intervention and Progress Scale for
Sexual Abusers with Intellectual Disabilities
(TIPS-ID) (McGrath, 2005)
Assesses only dynamic (changeable) factors
25 items in seven different treatment areas,
Likert-scale permits a scoring range from 0-75
Specifically created for and normed on IDD
offenders, can be used every 6 months
New instrument (2005), small normative sample
(n=87), bare-bones scoring
What are the ethical concerns around
confidentiality?
Explain the limits on confidentiality during the assessment and again
at intake– IDD recipients benefit from repetition
Explain in a way that the recipient can understand. Have them
repeat back what you said in order to check comprehension
(recipients will sometimes nod, even if they do not understand).
Will have to explain all over again to the recipient’s conservator
(legal guardian), if they have one.
Obtain releases to share information between all treatment team
members (i.e., probation officer, judge, provider agency, ISC,
psychiatrist, nurse, etc.). Call early and often.
Group—“whatever happens in here, stays in here—but if there is
something I think your staff needs to know, I’m going to tell them”
Provider staff should be warned about offender attempts at “secret
keeping”—if recipient tries to insist, refer to the clinical team
Individual and group therapy notes may be kept in a separate file
from other DMRS charts/documentation for the recipient– minimizes
the temptation to “browse through” sensitive treatment notes.
What is RHD Mainstay Memphis?
Transplanted model from a successful agency in
Philadelphia (operating since 1999)— five-site multidisciplinary consortium provides regular consultative
support, along with support and oversight from the parent
corporation
Supported living program (homes or apartments in the
community with 24 hour staff), small size (10 people max)
On-site integrated clinical staff for maximum residential
staff support (weekly meetings with all SO staff)
Recipients participate in weekly individual therapy, Social
Skills Group, and SO Treatment Group
Extensive and ongoing training for all staff
Crystal-clear communication and consultation pathways
Both programmatic and individualized restrictions that
have been OK’d and are continually overseen by the
Human Rights Committee
What is the RHD Nashville
Respite/Transition program?
Behavioral respite with SO services overlay
Most residents are stepping down from a higher level of
care, taking a “test run” with extensive support before
moving to a community SL provider
Single building, eight recipients housed on two different
“pods”, most recipients have SO histories
4-6 direct care staff 24/7, plus on-site management team
& clinical staff (1:1 staffing minimum for community trips)
Recipients under similar restrictions to the Memphis
program, staff receive similar specialized training
All recipients receive daily group therapy on various
topics (social skills, community living, etc.)
SO recipients also attend a weekly SO treatment group
and have access to individual therapy
What are the assumptions
underlying the programs?
Lifetime supervision model
Relapse risk is most effectively reduced through clinical
treatment, intensive supervision (based on individual
need), and recipient accountability
Community safety must sometimes take precedence over
personal freedom
Improvement is possible for non-SO issues
Improvement is possible for SO issues (i.e., increased
responsibility for offending behaviors, participation in
relapse prevention, etc.)
Overall goal is increasing progress towards selfmanagement
Movement towards healthy sexuality is possible, but the
process will be driven by a recipient’s individual abilities
and needs.
How is working with SO DMRS recipients
the same as working with non-SO
recipients?
Same expectations for recipient care by the state
Same DMRS audit and oversight procedures
(TEA, etc.,)
Same basic state–mandated training package
Process for reportable incidents, investigations,
and AOD is the same
Same money (must work within the fee structure
already in existence) (LON 6)
Same access to a higher level of care—police,
mobile crisis, behavioral respite, hospitalization
How is day-to-day service delivery
different in the RHD programs?
Sex offender status is discussed openly within the program
Sexual behaviors are discussed openly
Staff’s role as a protector of the community strongly emphasized
Inappropriate sexual behaviors are immediately addressed by both
staff and other recipients
Staff receive ongoing consultation and support around coping with
sexual issues
Direct care staff considered an active part of SO treatment intervention
strategy (SO treatment also happens outside the therapist’s office)
Recipients are encouraged to hold each other accountable for their
SO related decisions and behavior, and to take an active part in their
own relapse prevention
Social support between SO recipients is encouraged, with appropriate
supervision
More extensive discussion of potential community participation
activities and employment settings
Consistent team communication to reduce risk of triangulation
What does recipient supervision
look like on a day-to-day basis?
Shift in emphasis—the traditional model is 80% individual safety,
20% community safety
RHD model—50% individual safety, 50% community safety
Primary staff concern is less about limiting choice and more about
preventing an imminent harm situation from occurring
Preventing an offense IS protecting the recipient—protecting them
from retaliatory aggression, criminal justice involvement, or a return
to a more restrictive setting (hospital)
All SL recipients are LON 6, two staff available at all times
Staff monitor ALL social interactions (with other staff, peers, family,
adults in the community) and prevent interactions with children or
vulnerable adults
Staff always on the lookout for potential SO triggers in the
environment (i.e., moving recipients back away from the windows
when its time for school to let out). Direct care staff enlisted as
“clinical observers”, who actively gather info for clinical team about
internal and external triggers, deviant fantasy, and sexual behaviors.
What sort of training and support
do staff receive?
All regular DMRS mandated trainings
SO Basic training—all day training, required for staff who
are going to work in our SO homes. Also offered to
ISCs, POs, BAs, etc. free of charge
SO Booster training—two-hour training, required every
six months for all staff in SO homes (sometimes more
frequently, if there has been an incident or a progressive
discipline issue). Content is the same as the SO Basic,
just more compressed and with a different emphasis
SO Pre-group—group session for staff of all SO houses,
held weekly, run as a peer supervision group
On-site consultation—regular house visits by Project
Director, clinician, and RSM.
How can agency structure limit
opportunities to re-offend?
Model: Small size coupled with frequent opportunities for information
exchange and collaborative organizational structure—different staff
positions/roles are integrated and complementary rather than separate
Frequent communication and cohesive staff collaboration helps to close the
“gaps” that offenders may try to exploit
Provides consistent rules, behavioral expectations, and messages from all
staff
Restrictions necessary for safe community integration are understood by
recipients and authorized/supported by management—maximizes chance
that line staff will implement restrictions (i.e., management takes the heat)
Supports immediate but caring confrontation of inappropriate behaviors by
both staff AND peers
Multiple opportunities for staff support (both technical and emotional)
increases cohesiveness among staff and buy-in to the model
Limits grooming opportunities by consolidating the reporting of rare events
(i.e., the whole staff gets the whole story)
Increases coordination of care with outside agencies (psychologist
collaborates with PO about implementing restrictions and court orders then
communicates info to line staff, nurse follows up medication issues with
psychiatrist, reports back immediately to the larger group, etc.)
How do we cope with potentially traumatic
incidents (for recipients and/or staff)?
First response—follow all regular DMRS and RHD Mainstay
Memphis procedures (i.e., ensure safety, medical attention, AOD,
reporting to investigators, incident reports, etc.)
Acute incidents (staff): receive outside EAP referral for a critical
incident Debriefing (done 24-48 hours after the event, either on the
job site or in the therapist’s office, staff’s choice)
Chronic stress (staff): Helping Hands—RHD EAP program that
offers 10 sessions of free therapy, no strings attached
Pregroup meeting also helps staff process feelings
Acute incidents (recipients): Debriefing done by clinical team
member (24-48 hours)
Chronic stress (recipients): already in therapy, may look at
programmatic changes (i.e., altering peer’s behavior plan, changing
residences, etc.)
Management team response to perpetrator of the incident
Police involvement? (offender responsibility/staff rights vs. state
mandate)
Who can you contact for additional help or
support?
Division of Mental Retardation Services (DMRS)
– (800) 535-9725, www.state.tn.us/dmrs
Western TN DMRS Sexual Behavior Risk
Reduction Committee (SBRRC):
– Dr. Tucker Johnson (901) 745-7343,
[email protected]
RHD Mainstay Memphis (consultation for a fee):
– Dr. Michael Gavetti, (901) 377-7511,
[email protected]