Assessing and Treating Challenging Sexual Behavior

Assessing and Treating Challenging Sexual Behavior

People at Risk of Unlawful Behavior NADD 11/2/18 Marc Goldman [email protected] Historical Relationship of Psychology and Crime the moron---is a menace to society and civilization;---he is responsible to a large degree for many, if not all, of our social problems. Henry Herbert Goddard, PhD Director of the Research Laboratory of the Training School at Vineland, New Jersey, for Feeble-minded Girls and Boys MG 11/2/18 2

Prevalence of People With ID in Offender Populations Prevalence typically ranges between 1% to 8% (Winter et al., 1997; Gudjonsson et al., 1993 respectively) Estimated US prison rates vary between 0.8% - 19.1% Earlier stages of CJS (custody, local courts) estimated rates of 4.8% - 23.6% Up to 24% of defendants in the CJS may have intellectual disability, with higher rates were shown for Indigenous populations, for which the measure was not standardized (Hayes, 1997) Rates reported by probation were at 10% (Mason, 1998) MG 11/2/18 3 Personal Characteristics of Incarcerated Individuals with Intellectual Disability

Predominantly male Disproportionately non-Caucasian Predominantly functioning within the Mild Range of Intellectual Disability Older than the general prison population MG 11/2/18 4 There Are Multiple Factors Influencing Criminal Behavior

Lack of appropriate values Poverty Poor judgment Peer Influence Poor Problem solving skills Lack of social competence Poor impulse control Psychiatric Illness Substance use/abuse MG 11/2/18 5 Many External Variables/Setting Characteristics Are Vulnerabilities to Aberrant Sexual Expression

Learning conditions Victimization Lack of privacy Lack of prevention training; Knowledge and expectations Segregation Denial and minimization of support system and other systems MG 11/2/18 6

Sex Offender Treatment Literature Treatments that consist of modification of a single defect or pathology are not likely to succeed (i.e. organic treatment.) Programs that fail to identify the nature of the defect in need of modification are not likely to succeed. Sexual crimes result from complex interaction of physiological, cognitive, and situational variables. Treatment does not eradicate deviant interest Client is an active participant in treatment Treatment must include generalization procedures Self-reports are historically unreliable The offender is responsible and accountable MG 11/2/18 7 Treatment/Support/Safety Planning Is Likely To

Conflict with Self-Determination Primary goal (no more victims) is not determined by the individual. Limited confidentiality; No more secrets. Proactive restrictions go against our support philosophy. Treatment non-compliance might result in serious and. long-term consequences to the individual and the victim. Therapist role includes judgments, enforcement, and coordination of the network. If therapist is not involved, someone must fill those roles. MG 11/2/18 8 Supports Should Be Assessment Based Safety is the top priority Individual

Community Support professionals Denial/minimization will result in increased risk MG 11/2/18 9 Purpose of Offense Specific Risk Assessment Identify variables relevant to risk to reoffend Develop strategies to decrease the risk while developing strengths Determine type and frequency of supervision Develop home and community safety restrictions and controls Develop interventions to decrease relevant dynamic the factors; Build safety/strength MG 11/2/18

10 Multiple Risk Assessments Are Necessary Actuarial: Fixed variables of significance for male offenders Deviance Male victims Stranger victims Unrelated victims Prior sex offenses Non-sexual violence < 25 Offense Specific Empirically Guided Clinical Judgment Regularly Scheduled Progress/Risk Reviews Daily Monitors MG 11/2/18 11

Dynamic Variables Appear to be Strong predictors of Risk (Lindsay, et, al. 2008) The Short Dynamic Risk Scale (SDRS: Quinsey) Hostile attitude, coping skills, self care skills, consideration of others Emotional Problems Scale (EPS Prout & Strommer) A rating instrument for individuals w/ Mild ID Thought disorder, physical aggression, non-compliance, anxiety, distractibility, depression ,hyperactivity ,withdrawal, self-esteem, verbal aggression, somatic concerns, sexual maladjustment - - the SDRS and EPS resulted in predictions for the following year which were as significant or more significant than established static risk assessments, then one might surmise that dynamic variables may be at least as important and perhaps more important with sex offenders with ID (Lindsay, 2009) MG 11/2/18 12

Monitor Relevant Dynamic Variables On A Frequent Basis Victim access

Staff complacency* Substance use/abuse Anger/hostility v Emotional control Low self-esteem* Responsibility/impulsivity Positive coping skills v lack of such Lack of consideration for others/Antisocial attitude* Insulting, teasing, obnoxious verbal behavior Poor; self care/personal hygiene/domestic activity Compliance with supervision & treatment/low TX motivation* Cognitive distortions/Attitudes tolerant of sexual crimes* Denial of offensive behavior* *Lindsay, Elliot, & Astell (2004) MG 11/2/18 13

Some Offending Lacking Deviance; Counterfeit Deviance/Counterfeit Criminal Behavior Learning history Knowledge deficit Lack of privacy Inappropriate partner selection Modeling Lack of prevention training Agency restrictions/Agency attitude

Psychiatric influence Hingsburger, Griffiths, & Quinsey (1991) MG 11/2/18 14 Always Develop Assessment Based Safety and Intervention Plan/Behavior Plan Control social and environmental risk factors Interventions designed to reduce/eliminate dynamic internal factors; teach adaptive behaviors Establish crisis indicators Interventions for when crisis indicators are observed Established consequences of the target challenging behavior and make the individual very aware of such; Good Lives Model MG 11/2/18

15 Control/Restriction of Rights Must be considered for dangerous/high risk behaviors If deemed necessary, must be designed to efficiently suppress the individuals out of control behavior in the least intrusive manner But, such techniques; Violate our commitment to personal autonomy and dignity Does not solve the problem Risks making the problem worse Risks deterioration of relationship with support professionals Risks re-victimization Support professionals feel awful MG 11/2/18 16


MG 11/2/18 17 Case Study: Earl Earl is a forty year-old man who has been supported in a group home by the same provider for five years. He was referred after he lit paper in a trash basket on fire and placed it in his closet. The fire was discovered and promptly extinguished by alert support staff. Two years previous to that offense, he had set a fire in his home that resulted in $50,000 in damages. Two years prior to that, Earl set a mop on fire in his backyard. He is diagnosed with Moderate Intellectual Disability & Psychotic Disorder, NOS. He has maintained a job at a fast food restaurant for two years and is supported with a job coach. He is prescribed an anti-psychotic (Haldol). MG 11/2/18

18 Case Study: Steve Steve is described as an outgoing and helpful man who is motivated to interact with others. He enjoys music, attending concerts, playing records, and looking at books about music. He likes spending leisure time in the community making purchases, eating out, and walking around the down town area. Steve is diagnosed with: Autism Spectrum Disorder Mood Disorder, Not Otherwise Specified Mild Intellectual Disability Steve has a long history of aberrant sexual expression with children. On multiple occasions he has engaged in touching a child's or adult's foot while masturbating. MG 11/2/18 19

Steve; Past assessment of his sexual arousal determined; Adult and child bodies per se do not elicit sexual excitation Photographs of boys and girls elicited neutral sexual excitation when their feet were covered or not present in the photograph The most highly arousing photographs shown to him were of girls and women wearing flip flops and no socks. Small feet or feminine feet are more arousing than mens feet. When offered the choice of keeping a photograph of a seminude woman, child, or dressed woman in bare feet, Steve systematically chose the photo showing the bare feet. Sexual fantasies center around bare feet MG 11/2/18 20 Steve; Assessment Based Vulnerabilities

Autism Spectrum Disorder Lack of empathy Mood Disorder (Manic) Anxiety Trauma Survivor Lack of self-soothing skills Lack of emotional control; History of physical aggression/property destruction/self-injurious behavior History of deception Some victim type preference but opportunistic with all

MG 11/2/18 21 Treatment Considerations for Individuals with Autism Spectrum Disorders Rule out victimization/treat if indicated Teach self-soothing rather than processing trauma Teach good touch bad touch focus on following rules Support with close/restrictive supervision and frequent staff re-training Victims on the Spectrum often display affective dysregulation rather than intrusive thoughts & memories MG 11/2/18 22

Steve: Psychological/Habilitative Vulnerabilities Steve experiences significant anxiety; a frequently observed characteristic of individuals with Autism Spectrum Disorder. Many individuals not on the Spectrum obtain stress reduction through sexual activity. Many individuals who engage in aberrant sexual expression report that stress often proceeds planning and/or impulsively engaging in aberrant sexual expression. Steve's ability to recognize his anxiety fluctuates. On some occasions he recognizes his distress and he engages in selfcalming activities. On other occasions, he does not recognize that he is anxious. MG 11/2/18 23 Steve: Selected Proactive Interventions

It is critical to Steve's support that everyone working directly with him be familiar with the goals of this behavior plan. These individuals include volunteers accompanying him in the community. Everyone involved must read and comply with this plan. Consistency is a crucial element in providing adequate behavioral support. Support professionals will review the 6 Community Rules with Steve prior to every community outing. The rules are on a laminated card. Note that Steve has memorized the rule and will rapidly state them. Ask him to slowly read each rule. After reviewing the rules, ask Steve if he would like to carry the card and honor his choice. The rules on the card are as follows: MG 11/2/18 24 The Six Rules 1) Do not touch other people inappropriately

2) Do not go into a kids store or a store with a kids department 3) Stay with the support professional 4) Keep hands out of pockets 5) Do not touch myself inappropriately 6) Look at people at head level MG 11/2/18 25 When in the Community, Signs that Steve is at Increased Risk of Engaging in Aberrant Sexual Expression Maintains attention/focus on one selected individual Stares at the individual and/or looks at the individual "up and down." Remains near the individual Indirect/covert looking/staring at a potential victim.

Steve will roll his eyes, pace, and look downward as he keeps the individual in his peripheral line of sight. When he calls attention to one or more individuals in his vicinity wearing flip flops or other shoes that expose their feet. MG 11/2/18 26 When One or More of the Signs (previous slide) Are Observed Say in a supportive but confident manner, "You are in a Danger Zone. What do you do? Steve will then typically walk away from the individual and engage in distraction techniques that he has found effective. Specifically, he will cross his arms on his chest, tell himself to "look at face" and/or repeat what others are saying. He might also say, "I'm doing OK. I have my hands out."

If Steve does not immediately walk away, verbally prompt him to do so by saying, "You need to give him/her space." If Steve fails to walk away from the individual after two verbal prompts, terminate the trip and take him directly to his residence. When Steve calls attention to someone wearing shoes that expose their feet, prompt him per the Danger Zone prompt above. MG 11/2/18 27 Steve: Restrictions

18 offense-specific restrictions including; Access to potential victims Access/possession of pornography Room searches Unsupervised use of public restrooms Toy stores/book stores w/ children's section Housemates bedrooms Swimming pools Flip flops MG 11/2/18 28 Prior to Admission or ASAP (Better Late Than Never)

Do not assume that historical verbal reports are accurate Review all Risk Assessments Review most recent discharge summary if indicated Determine immediate support needs for safety Determine and plan treatment needs MG 11/2/18 29 Treatment/Community Support Safety of individual, peers, community, and support professionals should be reviewed daily Actively engage support professionals; Staff complacency results in reoffending Regardless of influential variables or counterfeit deviance, determine what protective supports and restrictions are indicated. Determine variables influencing the dangerous behavior and develop supports and safety

plan; Multimodal Biopsychosocial Treatment Consider limited confidentiality and network contact/support "No more secrets!" Keep everyone informed of risks, progress and set backs Provide offense-specific training, scheduled progress reviews, and ongoing supervision to those providing supports Review all aspects of safety and treatment/support plans on a frequent and systematic basis Treatment requires a respectful relationship and consists of numerous components that is very likely to include control and confrontation Do not try this alone! Assessment, development of interventions, and implementation of safety and treatment plans require active network involvement MG 11/2/18 30

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