Transcript The Teaching-Family Model and Sex Specific Treatment

Treating Youth With Sexual
Offending Behavior:
Integrating Clinical Services in a Teaching-Family Model
Program
Talon Greeff, MMHC
Director of Residential Care
UTAH YOUTH VILLAGE
(801) 272-9980
This training and additional resources can be found at:
www.utahparenting.org
Introduction
“…remember that although the goal when
working with juveniles who have committed
sex offenses is to help them stop their abusive
behaviors, they are children and adolescents
first.”
-Office of Juvenile Justice and Delinquency Prevention, 2001
Source Material
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U.S. Department of Justice,
“Juveniles Who Have Sexually
Offended - A Review of the
Professional Literature” (2001)
Network on Juvenile Offending
Sexually (NOJOS)
Association for the Treatments
of Sexual Abusers (ATSA)
National Adolescent
Perpetrator Network (NAPN)
Outline
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Introduction
Hallmarks of Best Practice
Teaching-Family Model Treatment Integration
Treatment of Sexual Behavior Problems (SBP)
Assessment and TFM
TFM Program Treatment Mechanisms
Working with schools
Lessons learned in application of clinical treatment
within a TFM program
Suggestions for implementation in a TFM program
Utah Youth Village Continuum
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Continuum – treatment
arc:
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Healthy sexuality
groups
Intensive outpatient
group
Foster care treatment
Group home treatment
in a community-based
setting
Utah Youth Village Continuum
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Continuum – treatment
arc:
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Step-down into foster
care and intensive outpatient
Intensive family
preservation
transitional services
Utah Youth Village Continuum
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Clinicians initially developed our treatment
using current research in treating youth with
sexual offending behavior
We have used outside clinicians for youth
with these issues in treatment foster care
The Teaching-Family Model works
seamlessly and effectively in enhancing
clinical treatment addressing sexual offending
behavior
Hallmarks of Best Practice
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National Adolescent
Perpetrator Network (1993)
suggests that satisfactory
treatment requires a
minimum of 12 to 24
months
Programs designed to focus
exclusively on sexoffending behaviors are of
limited value and have
recommended a more
holistic approach (Goocher,
1994)
Hallmarks of Best Practice
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Research is lacking on
what works best other
than it should be
“highly structured” and
include individual,
family and group
therapy
Hallmarks of Best Practice
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Lipsey and Wilson (1998) conducted a meta-analysis
of 200 experimental or quasi-experimental studies to
assess the effectiveness of treatment interventions
used with juvenile offenders
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Among non-institutionalized juveniles, treatments that
focused on interpersonal skills and used behavioral
programs consistently yielded positive effects
Other interventions that have been validated with chronic
delinquents, such as multisystemic therapy and
multidimensional treatment foster care, also are promising
approaches for juveniles who have committed sex
offenses (Borduin et al., 1990; Chamberlain and Reid,
1998; Swenson et al., 1998)
Hallmarks of Best Practice
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Report of the ATSA Task
Force on Children with
Sexual Behavior Problems
(SBP) found that
“…incorporating some of
these basic SBP elements
into evidence-based
treatments focused on the
highest priority problems
may be more feasible than
adding or stacking separate
therapies”
Hallmarks of Best Practice
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Social skills and
relationships
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Research repeatedly
documents that juveniles
with sexual behavior
problems have significant
deficits in social competence
(Becker, 1990; Knight and
Prentky, 1993)
Inadequate social skills,
poor peer relationships, and
social isolation are among
the difficulties identified in
these juveniles (Fehrenbach
et al., 1986; Katz, 1990;
Miner and Crimmins, 1995)
TFM Treatment Integration
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Provides a flexible,
customized approach
Emphasis on skills
development to address
maladaptive behaviors
Effectively addresses
mental health issues and
Diagnostic of Statistical
Manual (DSM) diagnoses
Integration of clinical
treatment for sexually
maladaptive sexual
behavior
TFM Treatment Integration
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Treatment providers should receive appropriate training
before they begin their work and thereafter on a continuing
basis.
Working with juveniles who have sexual behavior problems
is a challenging job
NAPN (1993) observed, "Systems must be aware of potential
emotional/psychological impacts on providers and take steps
to protect against or counter negative effects" (p. 46)
Consultation provides this support to both the TFM
practitioners but also to the clinicians
Clinicians receive one hour of consultation services weekly
with a supervisor trained in the TFM
TFM Treatment Integration
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Teaching-Family Model programs meet these
expectations:
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Individualized - The literature clearly supports the
importance of interventions that are tailored to the
individual juvenile
Strength-based - risk management most effective
in programs which address needs underlying a
juvenile's behavior emphasizing strengths and
positive supports
TFM Treatment Integration
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Research-based and empirical - Although efficacy
has not been established for many sex offender
interventions considered standard and required,
there are a wide range of interventions with more
of an empirical basis, particularly within the
juvenile delinquency field
Youth rights and oversight – Important caution is
that treatment efforts should not be harmful
Outline of SBP Treatment
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Sexually abusive behaviors range from noncontact offenses to penetrative acts
Offense characteristics include factors such as
the age and sex of the victim, the relationship
between victim and offender, and the degree
of coercion and violence used
Treatment typically provided to youth with
adjudicated or documented sexual offenses
Outline of SBP Treatment
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Identifying and managing feelings
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Feeling charts
Name what you are feeling right now
Controlling emotions – techniques, skills and mechanisms
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Role-play
Dialectic Behavior Therapy (DBT) skills
Normative sexual education and behavior
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Sexual timeline
“What is normal” and healthy sexuality
Sexual education 101
Outline of SBP Treatment
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Define, understand and identify thinking errors
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Use of thinking errors in everyday life
Use of thinking errors in sexual offenses
Identify thinking errors in others and self
Develop empathy
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Step one – Identifying feelings
Identifying feelings in others
Victim stories in the form of “victim cams”
Identification of thinking errors
Outline of SBP Treatment
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Managing impulses
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Social skills training
SUDS – Seemingly important decision
Thinking error avoidance
Learning about own triggers
Coping skills and mechanisms
Understand sexual offenses, patterns and behavior
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“Victim cams”
Sexual timeline
Thinking error examples
Sexual offense assignments
Outline of SBP Treatment
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Understand cycle and dynamics of sexual offending
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Identifying triggers and stressors
Cycle and build-up
People, situations and activities to focus on and those to
avoid
Relapse prevention skills
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Acting on feelings or “internal” state
Use of SUDS to stay safe
Personal rules for safety
Demonstrated use of protective skills and mechanisms
Healthy sexuality and sexual relationships
Outline of SBP Treatment
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Individual therapist
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Most of the “heavy lifting” as it relates to treatment occurs in
group
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“Customized” treatment vs. group therapy which does not always
have time to focus on individual issues
Preparation of major assignments which are passed off in group
therapy
Family therapy, including reunification and clarification
Demonstration of skills and “insight”
We have two groups weekly which are two hours long
Individual therapy at least one hour per week
TFM and Assessment
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Current standards
emphasize the
importance of
documentation and
specific descriptions of
the offense
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". . .sex offenders tend
to lie about their
offenses and are
unreliable and
deceptive in their
verbal reports…"
(Dougher, 1995)
Police reports
TFM and Assessment
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Avoid developing assessments based on just verbal
reports from parents and offending youth
Gather multiple sources of information
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Parents or guardians of juveniles should be involved in
the assessment and in the treatment process (Morenz and
Becker, 1995)
Comprehensive assessments should include clinical
interviews with the juveniles and family members
Evaluators should review victim statements, juvenile
court records, mental health reports, and school records as
part of their assessment (Becker and Hunter, 1997)
TFM and Assessment
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Psychological tests add a
"critical dimension" to
comprehensive evaluations
of juveniles who have
sexually offended
(Kraemer, Spielman, and
Salisbury, 1995)
“Sexual Behavior Risk
Assessment” a 16 hour
standardized assessment
developed by NOJOS
TFM and Assessment
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Thorough assessment
is critical because:
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Clinicians are correct in
judging recidivism 50%
of the time – same as
chance
Reduces time in
treatment
Polygraph motivates
youth to be more honest
about sexual history
and offenses
Assessment Tools
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The Estimate of Risk of Adolescent Sexual
Offense Recidivism (ERASOR)
Juvenile Sex Offender Assessment Protocol-II
(J-SOAP-II)
Polygraph Testing
Abel Assessment for Interest in Paraphilias
Others
The Estimate of Risk of Adolescent
Sexual Offense Recidivism (ERASOR)
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Empirically guided checklist designed to assist clinicians to
estimate the short-term risk of a sexual re-offense for youth
aged 12–18 years of age
Provides objective coding instructions for 25 risk factors (16
dynamic and 9 static)
Preliminary psychometric data (i.e., inter-rater agreement,
item–total correlation, internal consistency) were found to be
supportive of the reliability and item composition of the tool
Ratings significantly discriminated adolescents based on
whether or not they had previously been sanctioned for a
prior sexual offense
Juvenile Sex Offender Assessment
Protocol-II (J-SOAP-II)
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Checklist to aid in the systematic review of
risk factors that have been identified in the
professional literature as being associated
with sexual and criminal offending
Designed to be used with boys in the age
range of 12 to 18 who have been adjudicated
for sexual offenses
Can be used with non-adjudicated youths with
a history of sexually coercive behavior
Polygraph Testing
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Use of polygraph tests in
treatment programs for
juveniles who have been
sexually abusive is
increasing (National
Adolescent Perpetrator
Network [NAPN], 1993)
Facilitates more complete
disclosures of sexually
abusive behaviors and to
monitor compliance with
treatment
Polygraph Testing
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Research regarding the
reliability and validity of
the polygraph for assessing
juveniles who have
committed sex offenses is
very limited (Hunter and
Lexier, 1998
We use polygraphs at the
beginning of treatment to
evaluate the youth sexual
behavior timeline, number
of victims and severity of
the offenses
Other Assessment Tools
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Phallometric assessment is a direct measurement of an
individual's sexual arousal to deviant behavior
Potential ethical concerns using phallometric assessment with
juveniles (Bourke and Donohue, 1996; Cellini, 1995)
Abel Assessment for Interest in Paraphilias (Abel Screening,
Inc., 1996) is significantly less invasive than phallometric
assessment, and research conducted by the test developers has
shown good results
An independent study of the Abel Assessment's reliability and
validity raised questions about the use of this assessment
approach with juveniles (Smith and Fischer, 1999)
Clinical Treatment
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Therapists are
“experts” who provide
critical information
Must be consulted as a
valuable part of the
treatment team
Expert but not the
decision-maker
Clinical Treatment
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Consultants decide
how to mitigate risk
Clear understanding of
who makes the final
decision
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Either program director,
consultant or therapist
Recommend that it be
someone who is an
expert in TFM
Clinical Treatment
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Therapists make decisions
concerning safety
Do not let therapists take
control of treatment by
citing safety issues
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Therapist wants to take
away cell phone because the
youth may make calls to sex
lines is not a safety issue
Youth is “in cycle” and must
be limited in movement is
not safety
Written Assignments
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Clinicians assign:
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Timeline of sexual history
Definitions of sexual terms
Victim clarification assignments
Thinking errors
Assault characteristics
Seemingly Unimportant Decision (SUD) assignments
Journals with arousal logs
Treatment providers follow-up, provide feedback
and reinforces
Family Teachers and Treatment Parents
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Training on working with
sex offenders
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Dynamics
Risk factors
How clinical treatment is
completed
Reunification/clarification
The importance of skills
for treatment
Family Teachers and Treatment Parents
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How to support
clinical work
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Follow-up on
assignments
Normalizing sexual
experiences
Reports aberrant
behavior and
deviant thinking
Family Teachers and Treatment Parents
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No joking about sex offender treatment or
assignments
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Use appropriate language
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Nervous and embarrassed
Locker room mentality
Body parts
Sexual behavior
Pornography
Family meeting on healthy sexuality and
education just as with sexual victims
Program Mechanisms
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Risk Management
protocols
 Clinicians need to
external/objective
measures to assess risk
 Yearly or bi-yearly
review of “incidents”
and an assessment of
how to manage future
risk
Program Mechanisms
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Important to teach youth to
identify skills and coping
mechanisms they can use
to exit cycle and manage
impulses
Allow youth to choose
skills to help them in sex
offender treatment
“Girl Rule”
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Standards for acceptable
conduct with individuals
which have potential for a
sexual relationship
Primarily for the family
teachers and treatment
parents
Emphasize normative
behavior, integrating safety
and treatment
Working with Schools
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Provide customized assessments from
clinician
Train family teachers and treatment parents
how to interact with school officials
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Never call school first with an issue or problem
Pre-teach family teachers about how to
communicate information
Realize that school officials see your youth as
a risk
Lesson Learned
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Address thinking errors
Resistance of agencies to label children
“offenders” and instead call them reactive
may be appropriate for 12 years and younger
and if they have been victims
Cannot have these children with other
children
Lesson Learned
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Moved all our youth out of
foster care and group
homes
We had offenders in
treatment foster care, just
didn’t say, then made them
part of our continuum in
NOJOS
Mixed offenders with nonoffenders (still see agencies
who do this)
Lessons Learned
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Considerations
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Polygraph your youth
and their timeline
Know the pornography
that arouse your youth
Define pornography,
sexual content, mature
information, etc.
Clarification and
reunification before
home visits
Lessons Learned
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Safety issues decided by
therapist but don’t let them
cite safety issues to
override your program and
take it away from skill
building
Safety is important, yearly
risk assessment as a team,
barriers are critical
No children in home
Lessons Learned
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Safety plans
Family teachers need to own treatment,
therapist needs to own the sexual offending
psychodynamic parts of treatment
Therapists are not trained in the model and
want to develop their own program rather than
learn TFM
Lessons Learned
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Avoid “integrating” programs
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Integration of school, home and therapy stalled treatment
Work together on issues and sharing behavioral
information
Combining motivation systems between three
programs will frustrate and distract youth
Need to be successful in each domain to progress
Don’t let your clinicians or treatment providers tell
the school what to do
Lessons Learned
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Normalize sexual
behavior-don’t teach
them to look away
Teach them skills to
manage deviant
fantasies
Need perspective on
healthy sexuality
Lessons Learned
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Healthy masturbation
Family teachers need to
be able to teach about
sex, sexual
relationships and
appropriate sexual
behavior
Suggestions
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Groups need to be male therapist with female
or male
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Perception among referrers that female therapists
cannot help youth like male therapists
Can use Pathways book Pathways: A Guided
Workbook for Youth Beginning Treatment
(1996) by Timothy J. Kahn
Suggestions
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Need objective
measures for treatment
Erasor and J-Soap can
be used objective
measures for treatment
Clinical judgment has
been demonstrated to
be 50% accurate
regarding will/or will
not re-offend.
Program Completion and Aftercare
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Graduation, completion and participation
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Graduation-completed program and behavioral
indicators suggest internalizations of skills
Completion-completed program assignments but
some behavior suggests that internalization is not
complete
Program Completion and Aftercare
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Graduation, completion
and participation
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Participation-program
uncompleted
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Youth moving to intensive
out-patient
Youth moving to another
program
Can be difficult to make
recommendations to the
military or programs like
Job Corps
References
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Righthand, S & Welch, C (2001) U.S. Department of Justice,
“Juveniles Who Have Sexually Offended - A Review of the
Professional Literature”
Chaffin, M. et al., (2007) Association for the Treatment of
Sexual Abusers, “Report of the Task Force on Children with
Sexual Behavior Problems”
U.S. Department of Justice (2001) “Juveniles Who Have
Sexually Offended - A Review of the Professional Literature”
Timothy J. Kahn (1996) Pathways: A Guided Workbook for
Youth Beginning Treatment