Rockwood Psychological Services

1
Rockwood Psychological Services
Motivational Preparatory Program

• Liam Marshall
• www.rockwoodpsyc.com

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Others who have contributed to this presentation

• Bill Marshall
• Bruce Malcolm
• Yolanda Fernandez
• Geris Serran
• Heather Moulden
• Jean Webber
• Rose Spicer
• Jen Sparks

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Introduction

• Rationale
• Outcome
• Program description
• Implementation
• Introductory session
• Disclosure

4
Major Outcome Analysis

• Hanson et al, 2002
• Methodological Requirements
• Matched comparison untreated group
• Official recidivism index
• 43 Studies
• 9,000 offenders

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OVERALL OUTCOME FROM 43 INTERNATIONAL TREATMENT
PROGRAMS (Hanson, et al., 2002)
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Outcome Determinants

• Refusers
• Dropouts
• Completes treatment
• Gets it

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GOVERING PRINCIPLES OF TREATMENT

• Risk Allocate resources (treatment, release,
  and community supervision) differentially to
  high, moderate low-risk offenders
• Needs Target in treatment empirically
  established criminogenic needs
• Responsivity
• General
• learning style and ability of clients
• culture
• process issues (i.e., therapist characteristics,
  clients perceptions, and therapist-client
  relationship
• environment of treatment-physical and personal
  
• Specific
• attitudinal style of individual client
• clients world view
• day-to-day fluctuations in individuals

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Rationale for a Pretreatment Program

• Behaviour change more likely when
• Desire to change
• Belief that treatment will be beneficial
• Knowledge of how to change

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Rationale for a Pretreatment Program

• Evidence from Pretreatment Programs in other
  areas of Psychology
• Realistic expectations
• Self-disclosure
• Self-exploratory talk
• Participation
• Motivation

10
Resistance in Sexual Offenders

• Desire to continue behaviour for same reason it
  originally occurred
• Protect view of self
• Reaction to views of others E.g., police,
  courts, assessments
• Beliefs that change is not beneficial
• Belief that change is too difficult or impossible
• Beliefs about the efficacy of treatment media,
  other offenders, prison staff, friends and
  relatives

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Resistance in Sexual Offenders

• Lack of hope for future
• Previous bad experience with professionals
• Denial of a problem one-off event
• Concern about feeling worse
• Feeling alienated from others
• Fearing animosity
• Concern for loss of supports
• Concern over having to talk about private issues
  in public
• Hated school therefore will hate therapy

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Resistance in Sexual Offenders

• HMPS - Mann Webster
• 3 Groups
• Admit Enter Treatment
• Deny Refuse Treatment
• Admit Refuse treatment
• Conducted Interviews

13
Treatment refusal rates

• Across all areas of medicine, including
  psychotherapy, between 1/3 and 1/2 of patients do
  not comply with the treatment that is recommended
  or prescribed to them (Melamed Szor, 1999).
• Sex offender treatment refusal rates in HMPS
  treatment establishments averaged 52, range
  between 8 and 76.

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Resistance in Sexual Offenders

• System Factors
• Lack of trust in professionals
• Bad experiences
• System undermines treatment
• Courtesy of HMPS (Mann et al, 2001)

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Resistance in Sexual Offenders

• Psychological characteristics
• Reactance to pressure to enter treatment
• Lack of insight into own problems
• Future-focused coping style absent in refusers
• Courtesy of HMPS (Mann et al, 2001)

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Resistance in Sexual Offenders

• Social and family system
• Cultural issues
• Refusers concerned about lack of sensitivity to
  cultural issues
• Family factors
• Refusers family more likely to believe offender
  is innocent
• Courtesy of HMPS (Mann et al, 2001)

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Resistance in Sexual Offenders

• Treatment beliefs and knowledge
• Effectiveness
• Side effects
• Previous bad experience
• Stigmatization
• More than half of refusers expressed a desire to
  enter treatment that has a broader aim than
  addressing offending only
• Courtesy of HMPS (Mann et al, 2001)

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Conclusions - Mann et al, 2001

• A significant proportion of resistance could be
  reduced by some simple strategies.
• E.g.,
• Provision of information about treatment
• Focus on building rapport and trust
• Involve and inform non-treatment staff
• Establish Therapeutic Alliance

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Treatment Attrition Proulx et al, 2004

• N284, Prison, Psychiatric, Outpatient
• Noncompleters
• Institution 18.1
• Outpatient 38.3

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Treatment Attrition Proulx et al, 2004

• Assessed pre treatment
• Personality MMPI, RSQ
• Empathy, Self-esteem, Coping, Social
  Desirability, Intimacy, Fear
• Affective Hostility, Anxiety, Depression
• Cognitive Rape myth Molest scales, Blame
  attribution
• During treatment
• Stages of change, Therapeutic Alliance, Moos

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Treatment Attrition Proulx et al, 2004

• Pre treatment variables associated with attrition
• Empathy, antisociality, OCD, alcoholism, SSE
• Coping style distraction, coping using sex
• Treatment factors
• Therapeutic alliance commitment, working
  capacity
• Family environment conflict
• Group environment control

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Preparatory Program

• Outcome

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Preparatory Program Outcome

• Psychological Targets
• Readiness for Change
• Self-Efficacy
• Hope
• System Targets
• Movement through system
• Resources
• Returns to Custody and Recidivism

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Preparatory Program OutcomePychological Targets
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Preparatory Program OutcomePychological Targets
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Preparatory Program Outcome

• N 188 Treated Sexual Offenders
• Mean time on release 3.06 years
• Sample Matched for
• Age at assessment
• Date of assessment
• Length of sentence
• Risk assessment scores
• Victim characteristics
• Phallometrically assessed deviance

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Preparatory Program Outcome

• Offenders differ on
• Short-term differences
• Assigned program intensity
• Institutional placement
• Long-term differences
• Recidivism
• Return to custody
• Any recidivism
• Violent recidivism
• Sexual recidivism

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Matching Variables by Groups
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Victim Characteristics by Groups
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Risk for Re-offence Deviant Sexual Arousalby
Groups
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Subsequent Program Levelby Groups
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Subsequent Security Levelby Groups
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Type of Release from Custody by Groups
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Recidivisimby Groups
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Preparatory Program

• Program description

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PREPARATORY PROGRAM

• AIMS
• 1. Rehabilitation rather than punishment
• 2. Instil hope for the future
• 3. Become accustomed to group work
• 4. Become more comfortable/open about offence
• 5. Begin to identify victim harm

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PREPARATORY PROGRAM

• AIMS
• 6. Begin to identify reasons for offending
• - Why did you offend?
• - How did you give yourself permission?
• - How did you get access to victim?
• - How did you get the victim to cooperate?
• 7. Enhance motivation for treatment
• - Precontemplation
• - Contemplation
• - Action
• - Maintenance

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MAU Preparatory Program

• Description Began 1997
• 2½ hours per day, 2 times per week
• 6-8 weeks duration or until transferred
• 6-8 Sexual Offenders in group
• Open-ended (rolling)
• Cognitive-Behavioral Orientation
• Motivational

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MAU Preparatory Program

• Offenders
• 300 Sexual Offenders
• All risk levels
• Mixture of first-time, recidivist, and historical
  offenders
• Minimum sentence 2 yrs, Maximum Life/DO
• Exclusionary Criteria Appeal of Conviction or
  Categorical Denial

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Millhaven Preparatory Program

• Content
• orientation to treatment and assessment
• orientation to pen placement and treatment
  intensity
• orientation to risk
• identification of treatment goals

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Preparatory Program Content

• Pretreatment Interview
• Treatment
• Introduction to Treatment
• Disclosure
• Life History
• Non Specific Victim Empathy
• Four Stages of Offending
• Why did you want to offend?
• What did you say to yourself to make it seem
  okay?
• How did you get an opportunity to offend?
• How did you get your victim to cooperate

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Other Program Targets

• Self-esteem
• Loneliness
• Jealousy
• Coping Mood Management
• Intimacy Attachment
• Outside Issues

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Opening Session

• Strictly informational
• Group rules confidentiality, supportive
  challenges, attendance,
• orientation to treatment and assessment
• orientation to pen placement and treatment
  intensity
• orientation to risk

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Initial Disclosure

• Not challenged - can repeat disclosure later
  after alliance built
• Support and reward positives
• Ignore problematic statements
• Memory method

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Autobiography

• Ask for clarification and expansion dont
  challenge his version

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Victim Empathy

• Exercise List possible effects to victims of SA
  Long-Term Short-Term.
• Benefit
• Non-specific victim is less threatening
• Enables offender to consider effects in different
  areas some of which may not be overt

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Preparatory Program

• Implementation

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Open-Ended Groups

• Has no predetermined start or completion date
• As group members finish all treatment
  requirements new members are added
• All offenders complete the same components, but
  at different times
• The component any one group member is working on
  depends on how far along that individual is in
  treatment.

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Features of an Open-Ended Program

• Flexibility Can enhance learning with optional
  assignments
• Therapists have more decision making
  responsibility.
• High reliance on group process
• High reliance on therapeutic alliance

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Benefits of open-ended groups

• For Therapists
• Less chance of burnout
• Ability to roll in and out of group
• Experienced group members assist in challenging
  newer clients
• Greater flexibility to deal with issues
• outside issues

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Benefits of open-ended groups

• For Clients
• Repeated exposure to exercises spaced enough to
  avoid burnout
• Clients move at their own pace
• High functioning clients can move quickly
• Lower functioning clients do not feel pressured
  or inadequate
• Senior group members get opportunity to nurture
  new members

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Benefits of open-ended groups

• For System
• Can increase number of graduates
• Flexibility to deal with special cases
• Soon to be released
• Stabilization
• Lower burnout retention of experienced
  therapists

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Keys to running an open-ended group

• flexibility, flexibility and flexibility
• the ability to think on your feet
• an abundance of good therapist qualities
• understanding that everything that happens in the
  group provides an opportunity for learning
• willingness to hand some of the control over to
  the group as a whole

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Therapists in therapy

• What does the research show?

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Positive therapist features

• An ability to create an appropriate alliance with
  the client
• Ability to generate a belief in the possibility
  of change
• Providing opportunities for learning
• Instilling the expectation in the client that
  therapy will be beneficial
• Emotionally engaging clients

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Therapist Interpersonal Characteristics

• Empathy
• Genuineness
• Warmth
• Support
• Confidence
• Emotional responsivity

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Therapist Interpersonal Characteristics

• Open-ended questioning
• Directiveness
• Flexibility
• Encouraging active participation
• Rewarding
• Respectful
• Humour

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Features That Impede Change

• Confrontational behaviour
• Rejection of the client
• Low levels of interpersonal skills
• Lack of interest in the client
• Manipulation of client for therapist needs
• Anger and hostility

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Confrontation

• Particularly damaging to clients with low
  self-esteem.
• Associated with noncompliance in treatment.
• Clients react by
• discrediting or challenging therapist
• devaluing the issue
• agreeing on surface but dismissing the relevance
  of the issue
• (Annis Chan, 1983 Patterson Forgatch, 1985
  Cormier Cormier, 1991)

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Clients perceptions of the therapist

• Greater treatment benefits generated by
  therapists who are perceived as
• Confident
• Involved
• Focused
• Emotionally engaged
• Have positive feelings toward the client
• Directive
• Persuasive
• Sincere

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Therapeutic Alliance/Atmosphere

• therapists interpersonal characteristics and
  techniques clients perceptions of the
  therapist
• Key component collaboration
• Strict adherence to treatment manuals without
  establishing a good therapeutic alliance is not
  effective.
• Ratings of the therapeutic alliance have been
  shown to predict dropouts from treatment.

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Therapeutic Process in the Treatment of Sexual
Offenders
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CLIENTS PERSPECTIVE (Drapeau, 2005)

• 1. See therapist as crucial but also see value
  of procedures
• 2. Base judgments of quality of the program on
  the skills of the therapist
• 3. Good therapists are seen as honest,
  respectful, nonjudgmental, available, caring,
  confident, competent, and persuasive
• 4. Good therapists encourage discussion, listen,
  display leadership and strength, and maintain
  order
• 5. Do not respond to therapists who are
  critical, devaluing, or confrontational
• 6. Many clients who do well say they are able to
  re-enact aspects, with the therapist, of their
  past reactivation of attachment schemas with
  the therapist
• 7. Most prevalent interpersonal interactions
  involve therapist supportively challenging the
  clients in a caring manner
• 8. Clients desire to participate in decision
  making (work collaboratively) and they wish to
  attain mastery and feel competent

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GROUP CLIMATE(Beech Fordham, 1997 Beech
Hamilton-Giachritis, 2005)

• Used Moos (1986) Group Environment Scale 10
  subscales
• Pre to post-treatment changes produced a
  composite score to identify magnitude of
  treatment-induced gains
• Two of Moos subscales (Cohesion and
  Expressiveness) were significantly related to the
  composite measure of treatment gains
• - Cohesion includes involvement, participation,
  commitment to the group, and concern and
  friendship for each other
• - Expressiveness measures the encouragement of
  freedom of action and the expression of feelings

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EMOTIONAL EXPRESSION AND MASTERY (Pfäfflin et
al., 2005)

• Expressions of understanding (mastery) of the
  relevant issues appear first in treatment
• Emotional expression emerges later in treatment
• When emotional expressions first appear, mastery
  statements are reduced
• When emotional expression and mastery statements
  appear together, changes begin to occur quite
  rapidly

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Marshall, Serran et al., 2001

• Examined therapist features and their
  relationship to client changes in sexual offender
  treatment.
• Videotaped sessions rated and then related to
  pre-post treatment changes.

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Therapist features that were related to
significant treatment - induced changes

• Warmth
• Empathy
• Rewarding
• Directive

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Results of regression analyses
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Treatment strategies
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Treatment Strategies

• Three approaches have typically been used
• a) Confrontational approach
• b) Unchallenging approach
• c) Motivational approach

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7 Principles of effective therapy

• Encourage interaction
• Develop reciprocity cooperation among groups
  members
• Use active learning
• Give feedback
• Emphasize out of group practise
• Communicate expectations
• Respect diverse talents ways of changing
• (adapted from Chickering Gamson, 1994)

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How do I overcome resistance?

• Starts with interview
• Vocabulary
• Collaboration
• Information
• Confidence Reflection
• Face saving ways to change
• Patience

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How can I overcome resistance?

• Accept small steps
• Have an agenda but be flexible
• Give them something to look at
• Give them some work to do
• Dont take or let them take notes
• Ask for questions
• Allow them to be the expert
• Have fun
• Be responsive ask for and accept feedback
• Include whole group

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Adult learning

• After 15 minutes attention fades
• How to increase attention
• Increase importance of information
• Novelty Variety
• Increase demands on group members
• How to retain gains
• Active use of skills

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Interview Resistance

• Appeal
• Denial
• Memory deficit
• Fear of Identification
• Want to think about it
• Innocent but want treatment anyway

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Reducing Resistance The Interview

• Probe for treatment readiness informs treatment
  goals
• Probe to find out how much offender knows about
  treatment resistance may be due to uncertainty

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Interview II

• Try to get offender to take responsibility for
  entering treatment
• Outline benefits of participating and
  consequences of not participating
• Lay out group rules attendance, confidentiality,
  participation

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How to Increase Group Discussion Feedback

• Giving Feedback
• Think about what you want to say before you say
  it
• Direct your feedback to the person (Maintain eye
  contact, address the person)
• Observe your tone of voice and body language
  (angry/passive)
• Do challenge appropriately by identifying issues
  rather than attacking and blaming
• Do Not attack or blame Dont be a bully! This
  may feel satisfying but is not useful
• Stay on track
• Be specific Focus on specific points or
  behaviours rather than digressing or dwelling on
  the past
• Do give positive feedback
• Do challenge when necessary
• Use I statements rather than you statements
• Notice the response of the other person and learn!

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How to Increase Group Discussion Feedback

• Receiving Feedback
• Listen and Hear what is being said Do not
  assume you know what the other person is going to
  say, so wait to respond until you hear what has
  been said
• Do not interrupt or talk over
• Make sure you understand what has been said
  clarify the feedback and if you dont understand,
  ask!
• If you feel emotional about the feedback, it may
  be better to reflect on it after the session
  before saying anything
• If you receive similar feedback from more than
  one person, it usually means that people are
  noticing something important about you

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How to Increase Group Discussion Feedback

• Applying Feedback
• It might be helpful to make note of important
  feedback
• Ask trusted people how you can make the required
  changes
• Ask people to let you know when you are engaging
  in the desired/undesired ways of behaving
• Practice changes each day

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How to Increase Group Discussion Feedback

• When Feeling Frustrated At times we feel
  frustrated when giving feedback to others. It
  might be necessary to
• Repeat ourselves
• Challenge our own expectations
• Recognize that somebody may not want to change
• Change the way we are coming across everyone
  responds differently
• Remind yourself that your responsibility is to
  give feedback, not make somebody accept it!