New Directions in Sex Offender Practice

: The understanding

and treatment of sexual offenders from a neurobiological perspective

1 Anthony Beech

Centre for Forensic and Criminological Psychology

School of Psychology University of Birmingham, UK Email: [email protected]

www.birmingham.ac.uk/research/activity/dsa/forensic/cfcp/in dex.aspx

Overview

    Many sexual offenders have problems with impulsivity, general self regulation, empathy and perspective taking, problem solving and relating appropriately to others A significant number of sexual offenders will have attachment problems and will have been subject to early trauma The impact of all this is an individual who has problems with attunement with others, self-regulation and problem solving and who is extremely sensitive to potential threat, reacting at an emotional level For such individuals traditional talking therapies will be inadequate – need to work at an emotional level and use techniques that promote cortical growth 2

Hence the aim of the presentation is to:

   To give an overview of the neurobiological systems that are effected by early abuse/trauma Suggest some ways that go beyond the traditional talking therapies But before I get on to this, I will give a brief overview of the brain, especially the parts associated with trauma 3

Neurobiology 101

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The amygdala

• The amygdala is a set of interconnected nuclei (large clusters of neurons) found deep within the temporal lobes • Its functions are related to:  arousal  the control of autonomic responses associated with fear  emotional responses  emotional memory • and it is therefore centrally involved in attention, learning and affect. 5

• • • • The anterior cingulate cortex (ACC) first appeared in animals demonstrating maternal behaviour Therefore the ACC appears to provide the basic circuitry for communication, cooperation and empathy Being involved in the simultaneous monitoring of personal, environmental information and allocation of attention to the most pertinent information in the environment and a particular moment in time The ACC can be subdivided into affective and cognitive parts and integrates emotional and attentional processing. 6

The orbitofrontal cortex

• The orbital prefrontal cortex (OFC) can be considered as the apex of the neural networks of the social brain and is critical to the adaptation of behaviour in response to predicted changes in reinforcement • It bridges the cognitive analysis of complex social events taking place within the cerebral cortex, and emotional reactions mediated by the amygdala and the autonomic nervous system.

• The OFC therefore acts as a ‘ convergence zone information. ’ with its connections allowing it to integrate internal and external 7

The insular cortex

The insular cortex is a long neglected brain region that has emerged as crucial to understanding what it feels like to be human It is suggested that it is the source of social emotions (like lust, disgust, pride and humiliation, guilt and shame) It helps give rise to moral intuition, empathy and the capacity to respond emotionally 8

Risk factors for offending

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Risk factors for offending

   ◦ ◦

Developmental risk factors

◦ Abnormalities in foetal development Maternal smoking Foetal alcohol syndrome

Perinatal risk factors

◦ Obstetric complications

Postnatal risk factors

◦ Nutrition ◦ Brain injury ◦ Specific traumatic events 10

Post-natal risk factors: Trauma/abuse

◦ Exposure of the developing brain to stress hormones exerts consequences by:      Affecting gene expression Myelination Neural morphology Neuroegenesis synpatogenesis 11

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Areas of the brain said to be affected by early stress

     Corpus callosum Hippocampus Prefrontal cortex Visual cortex Auditory cortex 13

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Later effects of early abuse/trauma

   when recalling trauma the left frontal cortex shuts down (especially Broca ’ s area, the centre of speech and language) but the parts of the brain associated with emotional states and autonomic arousal, and the amygdala (centre for detecting threat) increases activity the frontal lobes become impaired and so the individual has trouble thinking and speaking ’ 15

Trauma

   Traumatic events overwhelm the brains capacity to process information Schore (1994, 1996, 2003) reported that children who experience chronic traumatic stress have adversely affected right brain development due to neuronal damage and atrophy As a result they do not deal well with stress, have difficulty understanding emotion expressed by others and thus have problems with empathy 16

Some neurobiological markers in sex offenders indicative of early trauma

◦ ◦ ◦ ◦ ◦ Lower IQs (Cantor et al., 2004) Poorer visuospatial and verbal memory scores Higher rates of left handedness (Cantor et al., 2005, 2005) Higher reported rates of having reported childhood head injuries (Blanchard et al., 2002, 2003) More likely to have been placed in special education facilities 17

Child sexual abuse, trauma, and subsequent offending and victimisation

    A 45 year follow-up study (Ogloff et al., 2012) of 2759 CSA victims abused between 1964 and 1995 It was found that CSA victims were almost five times more likely than the general population to be charged with with any offence compared to non-abused counterparts Charges with most marked elevations were sexual offences, violent offences and breach of orders Therefore, it can be argued that trauma may play a big part in subsequent offending 18

Traumatic brain injury Self-reported traumatic brain injury (TBI) in young male offenders (Williams et al., 2010)

       N = 186 TBI with a Loss of Consciousness (LOC) was reported by 46% of the sample Possible TBI was reported by a further 19.1% Repeat injury was common – with 32% reporting more than one LOC Those with self-reported TBI were also at risk of greater mental health problems and of misuse of cannabis.

Frequency of self-reported TBI was associated with more convictions Three or more self-reported TBIs were associated with greater violence in offences

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Treatments

    Many offenders have problems with impulsivity, general self regulation, empathy and perspective taking, problem solving and relating appropriately to others A significant number of offenders will have attachment problems and will have been subject to early trauma The impact of all this is an individual who has problems with attunement with others, self-regulation and problem solving and who is extremely sensitive to potential threat, reacting at an emotional level For such individuals traditional talking therapies will be inadequate – need to work at an emotional level and use techniques that promote cortical growth 20

More holistic approaches to treatment with offenders

  Traumatic experience is largely affective and somatic and so effective treatment must also address the body (Solomon & Heide, 2005) As the effects of trauma are often stored in body memories that verbal therapies cannot release, we need therapies that depend on action rather than verbalisation ’ (van der Kolk, 2003) 21

Chimes in with ideas from Bruce Perry

(seewww.childtrauma.org/index.php/services/neurosequential-model-of therapeutics   ◦ ◦ Neurosequential model of therapeutics (adapted) Therapies for different areas of the brain ◦ Brainstem – massage, rhythm (drumming, EMDR) ◦ Diencephalon (thalamus + hypothalamus) – Therapeutic massage, equine/canine interactions Limbic Cortex – Mindfulness/breathing techniques – traditional insight oriented/CBT 22

So let

’

s look at some of these, specifically:

   EMDR Mindfulness Biofeedback/breathing techniques 23

Eye Movement Desensitisaton and Reprocessing (EMDR)

     Controversial method developed by Francine Shapiro in 1989 Use of alternating, rhythmic stimuli whilst client focuses on traumatic image Strong anectdotal evidence but controlled studies variable Critics believe it is a form of exposure and that there is more evidence for the use of exposure – however not all clients can cope with exposure treatment Despite this, now included in NICE guidelines regarding effective treatments for PTSD 24

EMDR contd.

     Levin, Lazrove & van der Kolk (1999) Used brain scans before and after EMDR sessions with six subjects over three sessions Reported an increase in bilateral activity in the anterior cingulate cortex ( threat) modulates the limbic system and helps distinguish real from perceived Increased ACC indicates decreased hypervigilance Also increased pre-frontal lobe metabolism which suggests greater ability to make sense of incoming sensory stimulation and be more in control 25

Mindfulness?

     

What is mindfulness?

Mindfulness means paying attention in a particular way On purpose, in the present moment, and non judgementally (Jon Kabat-Zinn, 1994) A way of paying attention that originated in Eastern meditation practices Awareness of what is happening in the present moment, without being preoccupied with thoughts about the past or concerns about the future Can be developed through a variety of meditation exercises Mindfulness is not a relaxation technique ATSA 2010 26

Mindfulness and its effect upon the brain Role of Pre Frontal Cortex / Amygdala

Amygdala activation negatively correlated with mindfulness during affect labelling task Creswell et al. (2007) 27

Other effects of mindfulness

  Secure attachments between parent/ child promotes the growth of fibers in this pre frontal area (from D. Siegel, 2007, The Mindful Brain) Lazar et al., 2005 – increased thickness of middle pre-frontal area and the insula correlated with time spent in mindful meditation ATSA 2010 28

Forensic uses of mindfulness

 Reductions in hostility, self esteem, mood disturbance ◦ Samuelson et al., 2007  Reductions in uncontrollable aggressive behaviours ◦ Singh et al., 2003  For Conduct Disorder ◦ reduction in verbal/physical aggression, cruelty and non-compliance ◦ Singh et al., 2007 29

Controlled breathing techniques: What is it and how can it be incorporated into treatment?

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Biofeedback/breathing techniques for self-regulation

   Use of deep breathing techniques ◦ Leads to objectively measurable changes in physiology Primary change in physiology ◦ Heart Rate Variability (HRV) Secondary changes in physiology ◦ Skin Conductance Level (SCL) 31

Benefits

  Linked to psychological, cognitive and emotional flexibility

(Johnsen, 2003; Beauchaine, 2001; Butler, 2006)

Associated with: ◦ Greater socio-emotional competence (Butler,

2006, Bazhenova et al., 2001)

◦ More successful emotional regulation (Thayer,

2009)

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Controlled breathing techniques

 Many forms of meditation involve a focus on slow, deep breathing (e.g. Yoga techniques)  Breathing in a controlled manner exerts effects over the cardio-respiratory system and neural functioning  These effects may lead to improved regulation over emotional states 33

Healing Rhythms Biofeedback/breathing techniques

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Biofeedback/screenshots

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Effects of Slow Breathing on Heart Rate

 During expiration, activity of the vagus nerve increases  Increased vagal output leading to activation of the Parasympathetic division of the ANS ◦ Release of Acetylcholine slows heart rate ◦ Opposes the action of adrenalin, critical in

‘ fight or flight ’

behaviours 36

Effects of Controlled Breathing on HRV/ANS

Expiration Vagus nerve

Sympathetic

Noradrenaline - speeds up

Parasympathetic

Acetylcholine - slows down 37

Heart Rate and Heart Rate Variability (HRV)

 Slowing of heart rate linked with increases in the inter-beat interval of the heart  This is known as Heart Rate Variability (HRV) 38

Effects of respiration on HRV

Inspiration Expiration 39

HRV and PFC/Amygdala interactions

 Higher vagal output = greater HRV  Increasing levels of HRV linked with greater pre-frontal activation and decreased activity of the amygdala ◦ Similar mechanism may account for state of relaxation obtained during mindful meditation and effects on prefrontal-amygdala circuitry 40

Effects of Increased HRV

 Increasing HRV linked with: ◦ ◦ Psychological, cognitive and emotional flexibility Improved attention (Johnsen, 2003, Beauchaine, 2001, Butler, 2006) 41

Role of pre-frontal cortex/ amygdala

 Also slowed breathing can ‘ deactivate ’ the amygdala  Increasing HRV correlated with blood flow in pre frontal areas

(Thayer, 2009)

 Regaining pre-frontal control over dysfunctional emotional circuits 42

Pilot intervention with online sexual offenders

◦ • ◦ N=12 community male participants Recruited from Lucy Faithfull Foundation Inform Plus programme Age range = 24-62, M=42.5, SD=13.7

◦ Offences included possession, downloading and distribution of indecent images of children ◦ One offender previous conviction for sexual offence 43

Procedure

 Treatment group N=7, Control N=4  Treatment group attended Inform Plus programme early ◦ Took part in 8 weekly 15 minute biofeedback sessions ◦ Control group received no additional treatment  All participants completed a series of self report assessments pre- and post treatment 44

Self-report measures

 Emotion regulation questionnaire ◦ Reappraisal ◦ Suppression  Liebowitz social anxiety scale ◦ Fear/anxiety ◦ Avoidance  Beck depression inventory  State-trait anxiety inventory 45

Results - ERQ

29,00 28,00 27,00 26,00 25,00 24,00 23,00 22,00

ERQ Reappraisal

pre post 18,00 17,00 16,00 15,00 14,00 13,00 12,00

ERQ Suppression

pre post no treatment treatment 47

Results – Trait anxiety, depression Trait anxiety

62,00 60,00 58,00 56,00 54,00 52,00 50,00 48,00 46,00 44,00 pre post 31,00 29,00 27,00 25,00 23,00 21,00 19,00 17,00 pre

Depression

post no treatment treatment 48

Results – LSAS

28,00 26,00 24,00 22,00 20,00 18,00 16,00 14,00 12,00

LSAS fear/anxiety

pre post 28,00 26,00 24,00 22,00 20,00 18,00 16,00 14,00 12,00

LSAS avoidance

pre post no treatment treatment 49

Results

–

biofeedback group effect sizes

Social phobia fear/anxiety Social phobia avoidance ERQ – Reappraisal ERQ – Suppression STAI – trait anxiety BDI – depression ECQ – Rehearsal ECQ - Emotion Inhibition ECQ - Benign Control ECQ - Aggression Control

Mean

25.57

16.00

22.71

15.43

53.57

22.43

8.14

7.57

7.00

8.57

Pre SD

12.23

13.38

2.93

6.02

10.28

4.12

4.18

3.64

3.83

4.86

Mean

23.43

14.14

Post SD

13.51

10.85

28.71

14.57

46.14

18.00

6.71

6.86

7.57

9.29

7.20

6.02

10.96

8.45

3.04

2.12

2.37

2.14

Effect size

d’

0.52

0.49

3.23

0.45

2.20

1.99

1.28

0.80

0.59

0.65

Why is mindfulness/breathing techniques important?

• •

Neurological evidence

cortex ◦ ◦ ◦ ◦ ◦ ◦ Nine specific functions: ◦ Regulation of body systems Balancing emotions Attuning to others Responding flexibly Exhibiting insight Empathy Intuition ◦ Morality - Middle pre-frontal 52

So to sum up: Conclusions regarding other approaches to therapy

    ‘ Top-down processing i.e. CBT – use cognitive strategies to manage or inhibit problematic thoughts, feelings and behaviours – uses the neocortex and does not process episodic memories or resolve physiological hyperarousal Even with years of therapy, immediate responses to triggering stimuli tend to be physiological rather than logical Biologically informed therapy uses ‘ bottom-up ’ focuses on what is going on in the body processing which This helps clients connect with their bodies and feelings, facilitates learning to tolerate intense feelings and to release emotion appropriately (Solomon & Heide, 2005) 53

Final thought

Paul Gilbert (personal communication) says that in years to come not specific therapies like CBT/DBT etc. but therapies for particular bits of the brain 54

References - books

       Websites: Be Mindful; Compassionate Mind Foundation; Kristin Neff (University of Texas) Full catastrophe living – Jon Kabat-Zinn (Delta, 1991) Wherever you go: There you are – JKZ (Hyperion, 1994) The mindful way through depression – Williams, Teasdale, Segal & Kabat-Zinn (Guilford, 2007) Compassion focused therapy – Paul Gilbert (Taylor & Francis, 2010) The compassionate mind – Paul Gilbert (Constable & Robinson, 2010) Siegel, D.J. The Mindful Brain. London: Norton 55

References

–

other

    Ogloff et al. (2012). Child sexual abuse and subsequent offending and victimisation: A 45 year follow-up study. Trends in Crime and Criminal Justice, 440, June 2012. from: www.aic.gov.au/publications/current%20series/tandi/421-440/tandi440.aspx

Perry, B.D. (2006) The Neurosequential Model of Therapeutics: Applying principles of

neuroscience to clinical work with traumatized and maltreated children In: Working with Traumatized Youth in Child Welfare (Ed. Nancy Boyd Webb), The Guilford Press, New York, NY, pp. 27-52.

Teicher, M.H. (2007). Childhood abuse, brain development and impulsivity. Paper presented at the MASOC/MATSA Joint Conference, Marlborough, MA, available from: www.mclean.harvard.edu/pdf/research/clinicalunit/dbrp/mteicher talks/MASOC_MATSA_meeting.pdf

Van der Kolk, B. (2003). The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatric Clinics of North America, 12, 293-317.

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Other generally useful references

 Cozolino. L. (2006).

The neuroscience of human relationships: Attachment and the social brain. London: Norton.



Hodgins, S., Viding, E., & Plodowski, A.. (2009), The neurobiological basis of violence: Science and rehabilitation. Oxford: OUP



Romer, D. & Walker, E.F. (Eds.) (2007). Adolescent psychopathology and the developing brain. Oxford: OUP

 Beech, Carter, Mann & Rotstein (in press).

Handbook of forensic neuroscience

. Oxford: Wiley Blackwell.

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