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Sex Offender Treatment:The Brain, Attachment Theory, and Trauma Processing


Sex Offender Treatment:The Brain, Attachment Theory, and Trauma Processing Jay Adams, Ph.D Section I. Brain Facts Human brain development begins ... – PowerPoint PPT presentation

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Title: Sex Offender Treatment:The Brain, Attachment Theory, and Trauma Processing

Sex Offender TreatmentThe Brain, Attachment
Theory, and Trauma Processing
  • Jay Adams, Ph.D

Section I. Brain Facts
  • Human brain development begins in the last
    trimester of pregnancy.
  • An infants brain weighs about 400 grams at
    birth, and increases to 1000 grams in the first
    year of life.
  • An infant is born with the sympathetic
    branch of the ANS (arousal system) already
    activated, and sparse neural connections, but
    has twice as many neurons as an adult. The
    sympathetic nervous system promotes the infants
    attachment-seeking behavior because that will
    make survival more likely.

  • Right brain development has already begun in
    utero, while the left brain (linear processing)
    does not start to develop until near the end of
    the second year. The right brain is more
    responsive to the neurotransmitter dopamine and
    its pathways for more specific negative emotions,
    such as fear, distress, anxiety, depression, and
    disgust, which are registered in the amygdala.
    environmental experiences form part of the
    childs autobiographical memory laid down as
    chunks of emotionally pleasant or emotionally
    aversive experiences stored in the right brain
    (Allez, 2011, p40). We have access to these
    memories via the body and the senses (may be
    experienced in sudden flashes) rather than
    words, and they are referred to as implicit
    memory in contrast with verbal, or narrative,

  • When the infant brain perceives threat or
    stress, a cascade of stress chemicals flows along
    the hypothalamic-pituitary-adreno axis (HPA axis)
    increasing heart beat and breathing, tensing
    muscles, raising blood sugar and dilating the
    eyes. Long lasting high levels of anxiety lead to
    ongoing high levels of the hormone cortisol,
    which eventually destroys brain tissue and
    disturbs connections in various parts of the
    brain. the amygdala is left to fend for itself
    within a flood of ongoing internal and external
    perceived stressors, amplified by rivers of
    cortisol coursing through the body, sending the
    false message that today is as threatening as the
    original traumatic time (Badenoch, p.127).

  • Chronic stress may lead to excess pruning in
    certain brain regions. Both hemispheres go
    through various alternating spurts of
    development, through-out childhood. Within
    minutes of birth, an infant will see, hear and
    move to the rhythm of the mothers voice. Infants
    may be genetically programmed to seek and
    recognize the face of the mother. Newborns come
    equipped with only those preprogrammed emotional
    neural circuits that are necessary to protect
    from harm and promote survival.

  • These are (Panskepp, 1998)
  • SEEKINGactive arousal, curiosity, excitement,
  • CAREfeelings of warmth tenderness when
    w/others (safety)
  • PLAYjoy in interacting, promotes bonding
  • FEARroots of the fight/flight mechanism,
    triggers escapeSympathetic NS over-stimulated
  • PANICfear of separation from important others,
    includes loneliness, precipitates vocalizations
    to ensure survivalSympathetic NS overstimulated
  • RAGEeventually becomes the fight
    responseSympathetic NS overstimulated
  • LUSTsexual arousal and pleasure, later motivates

  • Take home message 1
  • Every human brain is unique but the processes
    that govern how human brains develop are
    universal. For more information on brain
    development, see Allez, 2011 Badenoch,
    2008Schore, 2003a b Siegel, 1999.

Section II Attachment The Unifying Concept
  • a.John BowlbyDefining features of attachment
  • John Bowlby developed attachment theory,
    proposing that attachment is the affective bond
    that develops between an infant and its primary
    caregiver(s). It begins to form as soon as the
    infant is able to distinguish one face from
    another (about 5 mos.). It is innate and
    provided by evolution to assure species survival.
    The quality of attachment evolves over time as
    the infant interacts with its caregiver(s), and
    is determined by both the interactions between
    the two and the state of mind of the caregiver(s)
    relative to her or his own attachment figures.

  • There are four defining features of the
    attachment bond
  • Proximity maintenance--infant wants to be
    physically close to its attachment figure(s)
  • Separation distress--infant experiences
    distress when separation occurs
  • Safe haven--infant retreats to its caregiver
    when anxious or sensing danger
  • Secure base--infant is able to explore the
    world knowing that its attachment figure(s) will
    be there and protect it.

  • Attunement means that the parent is
    sensitive to the infants verbal and non-verbal
    cues, able to enter the mind of the child
    (empathy) and respond appropriately and
    congruently with its affective state This is
    right brain to right brain communication.
    Attunement is central to the development of
    emotional regulation. Attachment bonds develop
    over the first two years of life and beyond,
    overlapping the most prolific period of brain
    development. Siegel The brain creates a core
    sense of self by embedding the response of the
    other in the neurons. We know that attachment
    status is not the same as temperament, because
    an infant can have a different attachment status
    with different objects, e.g., father or nanny.

  • b. Mary Ainsworthstrange situation
  • Mary Ainsworth first brought attachment
    theory to the US from Britain and developed a
    method of assessing and categorizing called the
    Strange situation (1978), which examines how
    toddlers between the age of 18 and 24 months
    react to being in a room filled with toys with
    mother and a stranger, react to mother leaving
    the room, and react to mothers return. Since
    then there have been thousands of observational
    studies, in numerous cultures, using this
    paradigm. Ainsworth initially identified 3 types
    of attachment patterns in toddlers, which she
    called secure, anxious/avoidant, and
    anxious/ ambivalent. With more studies, she
    became aware of a fourth pattern which did not
    fit any of the other three and included behavior
    which was bizarre, such as approaching and
    avoiding the attachment figure arching away
    angrily while at the same time seeking
    proximity. She called it disorganized

  • Humans are the only species whose young seek
    a person rather than a place when frightened.
    These contradictory child behaviors are believed
    to be what happens when the caregiver herself is
    the source of fear, and the child has no safe
    base. Creepy, frightening and bizarre maternal
    behavior may be the product of brief dissociative
    reactions triggered by the mothers own
    unresolved trauma or losses. Disorganized
    attachment is fear based. Most mothers do an
    adequate job, given that about 60 of the
    toddlers showed secure attachment. However there
    is evidence that this percentage is declining,
    possibly due to mothers returning to work before
    the child is 2 (Allez, 2011see Bruce Perry) due
    to economic necessity. Mothers do not have to be
    perfect, as research suggests that 32 attunement
    is enough to produce a securely attached child.
    About 13 of children show disorganized
    attachment, and these children are
    over-represented among mentally ill and criminal

  • c. Adult attachment research -- Mary Main the
  • Mary Main, a student of Mary Ainsworth,
    developed the Adult Attachment Interview (AAI,
    1993). Consisting of 20 questions, it takes 60-90
    min. to administer, with 2 weeks training,
    followed by 18 months of reliability testing.
    Scoring is complicated, consisting of assessment
    of the coherence of the subjects narrative.

  • According to Main, A coherent interview is
    both believable and true to the listener in a
    coherent interview, the events and affects
    intrinsic to early relationships are conveyed
    without distortion, contradiction or derailment
    of discourse, the subject collaborates with the
    interviewer, clarifying his or her meaning, and
    working to make sure he or she is understood.
    Such a subject is thinking as the interview
    proceeds, and is aware of thinking with, and
    communicating to, another thus coherence and
    collaboration are inherently inter-twined and
    interrelated. It is not the trauma history of
    the parent that is crucial, but the degree to
    which it has been processed and resolved.
    Disorganized individuals tend to have lapses in
    the monitoring of reasoning and discourse in
    their interview when discussing loss or
    experiences with abuse (Hesse, 1999).

  • Sample questions from the AAI
  • 1. Please describe in general terms your
    relationship with both parents as a child.
  • 2. Id like you to choose 5 adjectives that
    reflect your childhood relationship with your
    mother. This might take some time, and then Im
    going to ask you why you chose them.
  • 3. Id like you to choose 5 adjectives that
    reflect your childhood relationship with your
    father. This might take some time, and then Im
    going to ask you why you chose them.
  • 4.To which parent did you feel closest and why?
    Why isnt there this feeling with the other
  • 5.When you were upset or injured as a child, what
    would your parents do?
  • 6. What happened when one of your parents was
  • 7.What is the first time you remember being
    separated from your parents? How did you and they
  • 8. How did your parents respond if someone close
    to them died?
  • 9.Do you feel your parents were threatening to
    you in any way?
  • 10.Do you think that any of your childhood
    experiences hindered your development?
  • 11.Why do you think your parents behaved as they
  • 12. What is your current relationship with your
    parents like?

  • d. Six Ideas Basic to Attachment Theory
  • 1. During infancy through early childhood, the
    childs needs for attachment, when fulfilled,
    build an internalized sense of safety that is
    increasingly hard wired into the central nervous
  • 2. Through interactions w/early attachment
    figures, the child learns about self, others
    the world..
  • 3. Through early relationships, the child
    internalizes ideas about self and others, which
    become embedded in emotional and cognitive
    schema (or core beliefs) that form the basis
    for beliefs, interactions, relationships and
    behaviors, including the way in which the child
    comes to experience itself in society, and its
    capacity to understand and interact with others
  • 4. Attachment experiences are internalized in the
    form of felt security, and in internal
    representations of self, (self-confidence,
    self-efficacy) and others (ability to depend on).
  • 5. Through attachment experiences, children
    develop the ability to self-regulate. This occurs
    through the responsive attunement of attachment
    figures, i.e, the emotional repair of distress,
    repeated many times.
  • 6. Attachment patterns are relatively enduring.
    They provide the foundation upon which future
    social interactions and relationships are built.

  • e. Findings from Adult Attachment Research
  • Securely attached children become secure or
    autonomous adults.
  • Anxious/ambivalent children become preoccupied
    adults. They seek attachment but experience
    anxiety as a consequence. They show anxiety at
    mothers leaving, and are difficult to soothe
    upon reunion.
  • Anxious/avoidant children become dismissing
    adults. These children seemed content when mother
    was gone, and were not interested in
    re-connecting, but they scored high on
    physiological measures of anxiety while she was
    gone, indicating that they had already learned to
    hide their distress.
  • Disorganized children become fearful adults high
    among criminals and the mentally ill.
  • The attachment status of the parent will
    accurately predict the attachment status of the
    child 80 of the time. Although changes over time
    can influence the attachment status of a child,
    there is strong continuity between infant
    attachment patterns, child adolescent
    attachment patterns, adult attachment patterns.
    Changes can occur in either direction, but, for
    the majority of individuals, the manner in which
    they learned to manage anxiety early in life will
    continue unless their circumstances change or
    other experiences (positive relationships, good
    therapy) intervene.

  • Badenoch (2008) describes insecure attachment
    styles in terms that can help us understand many
    of our clients. research tells us that children
    who develop an avoidant attachment often have one
    or more parents with a dismissing state of mind
    with respect to attachmentThe child makes a bid
    for closeness, triggering the parents fear of
    connection. In response the parent sends a signal
    telling the child to move away children often
    learn early that attempting to be close costs
    them pain (pp.67-68). This is like living in an
    emotional desert devoid of interpersonal
    glue, and, at the extreme, may be related to the
    development of narcissistic personality disorder,
    because the child learns that contact with others
    is not going to be rewarding and that he must
    rely on himself.

  • In contrast, ambivalently attached persons have
    inner worlds that feel like a jungle rather than
    a desert. The word ambivalence reflects
    childrens uncertainty about how mother will
    respond to them. Will she provide safety, warmth,
    and empathy, or be so internally overwhelmed (and
    overwhelming) the she cant accurately sense
    their states of mind or care for their needs?
    (p.68) These mothers alternate between
    responsivity, and intrusiveness. When
    infantsencounter a terrified/terrifying parent,
    they have an insoluble problemIf we were to
    observe 1-year-olds with disorganized attachment
    in the Strange Situation with the unresolved
    disorganized parent, Even before mother
    leaves, they might reach for her while looking
    away, or freeze in a dissociated trance, or take
    two steps forward and then collapse on the floor
    (Badenoch, 2008, p.72). Slade (1999) In
    essence, attachment categories do tell a story.
    They tell a story about how emotion has been
    regulated, what experiences have been allowed
    into consciousness, and to what degree an
    individual has been able to make meaning of his
    or her primary relationships.

  • Attachment is not a technique, and not a
    theory of pathology, but a theory of child
    development, which means it deals with how
    development occurs, and is thus universal. It is
    a theory that helps us understand how connections
    are made and how they may have been damaged or
    distorted in individual clients. Attachment
    theory forms the background while treatment
    pursues the goals of social competence and
    connectedness, and teaches us how to build
    programs that will promote these goals.
    Attachment relationships contribute to other
    functions children must accomplish learning
    basic trust and reciprocity, exploring the
    environment with safety and security, ability to
    self-regulate, creating the foundation for
    identity, establishing a pro-social moral
    framework, generating core beliefs, developing
    defenses against stress and trauma. Attachment
    seriously affects the childs capacity to handle
    later trauma, loss and stress, into adolescence
    and beyond.

  • f. Attachment and Psychotherapy
  • The hallmark of secure attachment is the
    ability to reflect on ones internal emotional
    experience and make sense of it, while at the
    same time reflecting on the mind of another (core
    of empathy). These capacities are imbued in the
    infant through sensitive attunement of the
    caregiver. When a caregiver reads the verbal and
    non-verbal cues of the child and reflects them
    back, the child sees him or herself through the
    eyes of the attachment figure. Through this
    attunement and communication process, the seeds
    of the developing self are planted and realized.
    In treatment the client has the opportunity to
    have attachment patterns pointed out and examined
    in a safe environment.

  • Autonoetic self-knowing consciousness of
    traumatic events may be disturbed in individuals
    who have experienced trauma that remains
    unresolved (Siegel, 1999, 2001). This
    unresolved state of mind has important
    implications for how the mind functions within
    the interpersonal relationship of attachment.
    Some individuals may become flooded by excessive
    implicit recollections in which they lose the
    self-monitoring features of episodic recall and
    feel not as if they are intensely recalling a
    past event but rather that they are in the event
    itself (Siegel, 1995, 1996). Under such
    conditions, a parent may lose the capacity for
    flexible, attuned responses to a child. This
    mechanism may be one explanation for the finding
    that adults with an attachment classification of
    unresolved trauma or grief tend to have
    children who have a disorganized attachment. Main
    and Hesse (1990) have proposed that the parents
    frightened, frightening, or disorienting
    behaviors with the child lead to a paradoxical
    injunction in which the child is terrified by the
    very figure who is supposed to be the source of
    comfort and soothing (Main, 1999). Children with
    disorganized attachment have been shown to be
    vulnerable to the development of dissociative
    symptoms later.

  • In its essence, unresolved trauma or grief
    can be conceptualized as a lack of cortical
    consolidation regarding that aspect of an
    individuals life history and may clinically be
    seen as the absence of a coherent narrative
    version of a traumatic experience. Unresolved
    states remain isolated from the normal
    integrative functioning of the individual and can
    impair flexible responsivity and the development
    of a coherent sense of self. Unresolved trauma
    leaves the individual prone to an unstable state
    of potential implicit activations that tend to
    intrude on the survivors internal experience and
    interpersonal relationships. For a parent, such
    unresolved states of mind can have a devastating
    effect on the individuals children. Parental
    disorganization due to unresolved trauma or grief
    is associated with the childs development of
    disorganized attachment and risk for dissociative
    adaptations. Preventive measures involving
    assessment and intervention at the level of
    unresolved parental grief and trauma might
    provide an effective strategy for promoting child
    mental health. Excerpted from Seigel (2001).

  • Attachment theory is currently the dominant
    theory in clinical psychology, and is being
    increasingly applied to forensic populations,
    including sex offenders. This is a good thing but
    there are a few possible sources of confusion in
    the literature. There is often a failure to
    differentiate among the different styles of
    insecure attachment, and this may create the
    impression that all sex offenders have
    disorganized attachment, or are impaired to the
    same degree. Given that sex offenders are known
    to be a very heterogeneous group, it seems
    likely, for example, that some have the capacity
    for empathy but lack sufficient impulse control.
    Insecure attachment may be confused with Reactive
    Attachment Disorder (RAD), which implies NO
    attachment and fosters the notion that most, or
    many, sex offenders are psychopaths and cannot be
    treated. Recently developed self-report tools to
    measure attachment status may be creating
    misinformation. Implicit memories are often
    present but not available, and there are other
    reasons for inaccurate reporting of available
    memory, such as denial and the need to protect
    parental figures. There is no short cut to
    learning about a clients attachment status. The
    most accurate and valuable information is
    obtained from taking a careful and detailed
    history. How this information can be used in
    therapy with sex offenders is described below in
    Section IV.

  • Take Home Message 2
  • Asking Was this sex offender sexually
    abused? is not sufficient because the pathway
    from victim to perpetrator is more complex. In
    order to do an accurate evaluation and plan
    effective treatment, obtain as much data about
    the individuals attachment history as possible,
    and keep assessing it as you have more
    opportunity to observe the clients behavior.

  • Section III.Complex Developmental PTSD (DESNOS)
  • The majority of sex offenders have suffered
    some form of childhood abuse, e.g., Hanson (1997)
    found that 75 of 409 sex offenders in treatment
    reported being sexually, physically and/or
    emotionally abused. However most of them never
    fit the specific diagnostic criteria for PTSD,
    and their trauma symptoms are often overlooked or
    misdiagnosed. The reason for this lies in part in
    the historical circumstances under which the
    criteria for PTSD were developed. This occurred
    in the 1970s, and were derived primarily from
    studies of returning Viet Nam veterans. Obviously
    war veterans experience trauma primarily in late
    adolescence or early adulthood. At the same time
    PTSD was being defined, the womens movement was
    bringing sexual violence against women and
    children out of the closet, so increasing numbers
    of therapists began treating adults who had been
    abused as children. Many of these therapists
    noticed that their clients frequently displayed a
    set of symptoms that were pervasive but not as
    acute as those seen in PTSD. This set of
    symptoms is known by a variety of names, the two
    most common being complex developmental PTSD
    and DESNOS--Disorders of Extreme Stress Not
    Otherwise Specified (Luxenberg et al., 2001).

  • Adults abused as children differ from war
    veterans in two significant ways. In the vast
    majority of child abuse cases, at least some of
    the trauma suffered was at the hands of one or
    more trusted individuals who should have cared
    for and protected them. Secondly, childhood
    trauma occurs at a time when the human brain is
    not fully developed and is much more likely to be
    affected by adverse circumstances (Perry, 1997
    Siegel, 1999). The resulting syndrome or symptom
    pattern consists of 6 sets of symptom clusters,
    which must be addressed in order to achieve
    lasting treatment effects with many sex

  • A. Affect dysregulation (poor impulse
  • The first group of symptoms have to do with
    difficulty modulating and tolerating strong
    emotion, high reactivity to emotional and sexual
    stimulation, slow return to baseline, and an
    inability to self-soothe. Individuals with
    affective dysregulation tend to overreact to
    minor stress, becoming easily overwhelmed because
    they experience their emotions more intensely
    than other people. They have trouble calming
    themselves once emotionally aroused, and may
    engage in extreme and/or self-destructive
    behaviors in an attempt to provide distraction
    from emotional pain. Maladaptive attempts to
    regulate affect can include eating disorders,
    substance abuse, compulsive sexual activity,
    self-injury, and suicidal preoccupation. In
    forensic settings, where staff are often
    unfamiliar with the literature on early trauma,
    this emotional lability is frequently mistaken
    for bi-polar disorder. Another form of
    distracting behavior, excessive risk taking, may
    be incorrectly interpreted as an indicator of
  • What causes affective dysregulation?

  • Infants are born with the capacity to
    experience certain emotions which have a survival
    value. When their innate startle response is
    frequently triggered by environmental events,
    such as parental yelling or fighting, breaking
    dishes or furniture, or other loud noises, a
    kindling effect occurs. Each time the startle
    response is triggered, the connections in the
    brain which cause it are strengthened, and this
    in turn makes it more likely to be triggered in
    the future. As the connecting fibers become more
    numerous, it takes less and less to trigger the
    response, making it more likely that it will
    recur. What results is a child who is
    hyper-aroused and may respond with fear to
    stimuli that other children would perceive as
    neutral. The parts of the brain which are
    involved are those which regulate emotional and
    sexual arousal, the amygdala and the hippocampus
    of the limbic system.

  • Prolonged hyperarousal while the brain is
    developing, without repair through maternal
    attunement and soothing, causes difficulties in
    affect regulation. This means that the individual
    becomes emotionally vulnerable, highly reactive
    to emotional/ sexual stimuli, with an intense
    response to such stimuli and a slow return to
    baseline, and lacking the ability to inhibit
    inappropriate behavioral responses to strong
    emotion (think Hansons difficulties with
    general self-regulation and sexual
    self-regulation ). This condition is the result
    of repeated experiences in which the infant has
    been emotionally stimulated and upset, without
    consequent repair by the attachment figure,
    leading to an alteration in their brains ability
    to handle stress and to modulate emotional/sexual
    arousal. Punishment cannot decrease
    impulsivity, and increased impulse control cannot
    be faked.

  • Treating Affect Dysregulation with
    Dialectical Behavioral Therapy (DBT)
  • A substantial proportion of sex offenses are
    impulsive, and therefore very likely not driven
    by paraphilias. The central tenet of Relapse
    Prevention (and all CBT) is that thoughts
    determine feelings and behavior, and that beliefs
    and thoughts are under voluntary control.
    Developmentally, we experience feelings before
    we develop rational thinking. The feelings we
    experience very early in our development, and how
    our caretakers respond to those feelings,
    determine both how our nervous systems respond to
    stress and how we interpret the world around us.
    Marsha Linehan, the originator of Dialectical
    Behavior Therapy (DBT), states, The fundamental
    message given to clients in DBT is that cognitive
    distortions are just as likely to be caused by
    emotional arousal as to be the cause of the
    arousal. Her work (1993) with borderline
    personality disorders has specifically targeted
    the problem of affect dysregulation with
    promising results. It has been found to be
    effective with complex PTSD clients, so there is
    every reason to believe that it can be equally
    effective with sex offenders who have poor
    impulse control and other indicators of problems
    regulating affect.

  • Linehans approach is based on two fundamental
    assumptions(1) that distress tolerance and
    emotional regulation are internal skills that can
    be taught but require repeated practice to learn,
    and (2) that problems with affect regulation do
    not reflect a structural defect but rather
    arise from developmental disruptions. Such
    problems can be addressed individually or in a
    small group of 4 or 5, which typically takes
    about 6 months with severe borderlines in
    outpatient therapy. With sex offenders, it should
    be done before processing offense behavior
    because it will reduce the risk of emotional
    overwhelm and consequent flight from treatment,
    and will provide the offender with skills to
    handle the strong affects that are likely to
    emerge during offense-specific therapy.

  • Linehan recommends that problem behaviors
    related to affect dysregulation be approached in
    a specific order. The first type of behaviors
    that must be dealt with are suicidal ideation
    and/or behavior, and self-injurious behavior.
    Self-injury is much more common among sex
    offenders, and other forensic clients, than is
    generally thought. In forensic settings, such
    behavior is considered by custody staff to be
    either an attempt at suicide, or a manipulation
    designed for secondary gain. In fact, the vast
    majority of self-injury is never known to staff
    and clearly serves other psychological purposes
    than suicide or manipulation, because it is done
    in secret. Opportunities for therapeutic work
    are missed when staff do not know how to respond
    to self-injurious behavior in any other way but
    punishment. Self-injurious behavior may have
    different meanings for different clients, or
    multiple meanings for the same client.

  • It is important to understand self-injury
    because it may result in accidental death or
    dangerous infections from untreated wounds.
    Linehan stresses that these behaviors must be the
    first focus of treatment because of their
    potential lethality. Her approach is especially
    applicable to sex offenders because it conveys an
    immediate message that treatment is going to
    delve into some very private and difficult areas,
    but hopefully at the same time offers that this
    will be done in a supportive and empathic way.
    Clients are provided with large file cards
    (diary cards) at each session and are
    instructed to record any experiences of suicidal
    feelings and behavior, and of self-injury. Each
    experience is then processed in the group with
    regard to what feelings or events may have
    triggered it, any memories associated with it,
    etc., in much the same way that a Behavior Chain
    would be constructed in Relapse Prevention work.
    The goal is to identify maladaptive behaviors,
    behavioral deficits that are maintaining them and
    environmental and behavioral events that may be
    interfering with more appropriate responses.
    Clients are taught ways to tolerate the stress of
    unpleasant feelings, more adaptive behavioral
    responses to perform when they occur, and
    emotional regulation skills.

  • Distress tolerance skills include
    distraction, ways to self-soothe, and learning to
    bear the moment through the use of core
    mindfulness skills such as relaxation training,
    meditation, prayer or whatever technique the
    client feels drawn to and is likely to use.
    Skills to increase interpersonal effectiveness
    include deciding on goals, practicing assertion
    training and limit setting, modeling, and role
    playing. Emotional regulation skills involve
    learning how to identify and label affect by
    becoming more aware of body cues, reducing
    vulnerability to hyper-emotionality through the
    use of stress reduction techniques, increasing
    the frequency of positive emotional events, and
    developing an ability to experience emotion
    without judging, rejecting, or fearing a loss of
    control. When everyone in the group has been
    able to eliminate suicidal ideation and
    self-injury, the therapist then moves on to other
    behaviors that interfere with therapy, including
    things like coming late or missing sessions, not
    paying in timely fashion, etc.

  • Finally, the therapist turns the focus to
    behaviors that interfere with the quality of
    life. These include serious substance abuse,
    severe eating disorders, high risk and sexually
    compulsive behaviors, repeated hospitalizations,
    being in abusive relationships, etc. Most
    clinicians who treat sex offenders are well aware
    that many of them continue to masturbate to
    deviant sexual fantasies while in treatment. A
    primary weakness of Relapse Prevention is that it
    unrealistically assumes abstinence from the
    beginning. A DBT group, which should precede
    offense-specific treatment, is the ideal place to
    introduce the concept that continued masturbation
    to deviant fantasies is detrimental to recovery
    and to provide the client with the tools to
    interrupt deviancy and replace it with more
    appropriate behavior. This enables the client to
    begin the actual sex offender treatment with a
    much greater sense of control and understanding,
    so that the processing of his offenses, or
    listening to others offenses, will be less
    likely to induce a lapse. While Linehans
    approach consists of some fairly traditional
    cognitive-behavioral techniques, she considers
    them as merely a first step in preparing clients
    for more in-depth work on trauma resolution. She
    recognizes that early treatment of adult
    survivors of abuse in many instances put
    premature emphasis on processing traumatic
    incidents too soon, overwhelming clients and in
    some cases causing them to leave treatment in
    worse shape than before (Briere, 1996).

  • Toxic Shame
  • The parasympathetic branch of the ANS
    (brake system) is developing when a child is
    learning to walk, experiencing new freedom and
    excitement in his ability to explore. At the same
    time, the orbitofrontal cortex in the prefrontal
    region of the brain has matured to a point which
    allows for mental self-representation and
    self-consciousness, i.e., the emergence of
    awareness of self as a separate entity. Schore
    (2003) has described shame as the emotion evoked
    when a childs arousal state is not met with an
    attuned response by the parent. Some shame is
    inevitably experienced as children learn to
    self-regulate and to restrain some of their
    impulses, but its toxic effects can be avoided by
    redirecting the childs attention to something
    else. Unfortunately a parental NO is often
    uttered more to meet the parents needs than
    those of the childs, and under those conditions
    is less likely to be followed by repair.
    Shaming is not a good parenting strategy.
    Shame-induced interactions coupled with
    sustained parental anger and/or lack of repair of
    the emotional disconnection lead to
    humiliation, which Schore has proposed is toxic
    to the developing childs brain (Siegel, 1999).

  • Many of the practices common in the
    treatment of sex offenders elicit shame but it
    is often not recognized or dealt with in
    treatment. Some examples are the preparation of
    a detailed timeline and autobiography, the
    detailed processing of crimes through the
    construction of a Behavior Chain, phallometric
    assessment, and writing unsent letters to
    victims, not to mention dealing with their own
    abuse. Individuals who have difficulty with
    affect regulation are likely to become
    overwhelmed and to either increase externalizing
    the blame for their behavior, flee from
    treatment, and/or act out in other ways. DBT can
    be helpful to inoculate clients against toxic
    overwhelm, but shame is likely to be elicited
    repeatedly in sex offender treatment. It may be
    experienced as a feeling of being under a
    magnifying glass or the imposter syndrome a
    sense of low self-esteem, worthlessness, being
    defective or empty inside, and unlovable. Visual
    cues are a lowering of the head and avoiding eye
    contact, or conversely, staring with a look of
    contempt (a common prison behavior). It may be
    misinterpreted as anxiety. It offers a crucial
    opportunity for repair.

  • A review of the literature on shame and guilt
    by Proeve and Howells (2002) found that proneness
    to shame is correlated with irritability,
    suspiciousness, resentment, anger arousal, and
    the externalization of blame. They note that
    shame inhibits empathy, and caution that victim
    empathy work which stresses victims experiences
    is likely to trigger a feeling of personal
    threat, which leads to the emotion of shame. In
    research on large samples of domestic violence
    perpetrators, Dutton (1998) concluded that the
    primary emotion behind wife battering is shame
    that has been converted to anger. These findings
    indicate that our attempts to increase empathy in
    sex offenders may often been counter-productive.

  • B. Disturbances in attention and consciousness
  • A second group of symptoms are disturbances
    in attention and/or consciousness. It is not
    uncommon for individuals who were severely abused
    at an early age to have memory gaps, in some
    cases for large segments of their childhoods.
    Such gaps may occur as a result of dissociation
    or because sexual abuse often takes place at
    times when children are asleep. Briere (2002) has
    noted that avoidance strategies are used by
    survivors of abuse a) to reduce awareness of
    potential environmental triggers b)to lessen
    awareness of memories once they are triggered
    and c) to reduce
  • cognitive and emotional activation once CERs
    conditioned emotional responses to these
    memories are evoked (p.10). Avoidance strategies
    are self-reinforcing because they reduce
    emotional pain, but unfortunately they also
    contribute to the failure to develop a strong
    sense of identity discussed below under
    c.Disturbances in self-perceptions/impaired

  • Dissociation may be mistaken by therapists as
    resistance or lack of motivation, for example,
    when clients dont remember things from session
    to session, forget to do homework, tune out
    during victim empathy films, etc. It got a bad
    reputation during the repressed memory wars as
    strange and bizarre but is actually something
    that most of us have experienced, at least in
    mild forms. It is a normal self-protective
    reaction, but must be addressed early in
    treatment and replaced by more adaptive ways of
    dealing with pain, because of its interference
    with treatment and deleterious effects on the
    development of the self. Clinicians need to be
    familiar with the signs of dissociation, and
    assessment for it should be an ongoing part of
    treatment with sex offenders. Memory gaps may be
    addressed in treatment by encouraging clients to
    talk to non-abusive relatives, look at childhood
    photos or draw the floor plan of where they lived
    during the time when they believe their abuse

  • During the first year of life, memories that
    contain elements of behavioral impulses,
    sensations, perceptions and emotions are encoded
    by the amygdala without conscious awareness. With
    repeated experience, these implicit memories
    cluster into mental models as our higher
    cognitive processes develop. processes in the
    amygdala develop generalized, nonverbal
    conclusions about the way life worksthe essence
    of mental models. These conclusions create
    anticipations of how life will unfold and remain
    largely below the level of conscious awareness,
    guiding our ongoing perceptions and actions in
    ways that tend to reinforce the foregone
    conclusions (Badenoch, 2008, pp.24-25).

  • C. Disturbances in self-perception (impaired
  • A third group of symptoms concerns
    disturbances in self-perception, or impaired
    self-reference (Briere, 1992). Childhood abuse
    survivors are vulnerable to a host of painful
    emotions and cognitive distortions. Some of
    these long-term effects are the result of direct
    messages from perpetrators, who often blame the
    victim and/or invalidate the victims feelings
    (Shut up or Ill really give you something to
    cry about I know you want it.). In addition,
    the immature, egocentric nature of a young
    childs thinking virtually guarantees that the
    child will blame himself for the abuse, creating
    a sense of being damaged goods.

  • Physical and sexual abuse are also emotional
    abuse because they represent an attack on the
    self The assault is not only upon the physical
    body, but upon the individuals perception of the
    self as competent, and among other things, the
    perception that the world is beneficent or
    neutral, rather than innately hostile (Navarre,
    1987). In addition, the use of dissociation and
    the necessary adaptation of scanning the external
    environment for signs of danger occur at the
    expense of the survivors awareness of internal
    cues. Thus severe child maltreatment may
    interfere with the childs access to a sense of
    self--whether or not he or she can refer to, and
    operate from, an internal awareness of personal
    existence that is stable across contexts,
    experiences, and affects. Without such an
    internal base, the survivor is prone to identity
    confusion, boundary issues and feelings of
    personal emptiness (Briere, 1992, p.43).

  • One of the most common characteristics of sex
    offenders described in the literature is that
    they are they are out of touch with their
    feelings and bodily cues. Lisak (1997) has
    examined the link between male gender
    socialization and the perpetration of sexual
    abuse. He notes that boys learn at a very early
    age that there are many emotions that they are
    not allowed to display. Except for anger,
    virtually all the emotions associated with
    childhood abuse are off limits for boys fear,
    anxiety, helplessness, humiliation, shame,
    vulnerability. Once evoked, these states are
    likely to create distress, since they are
    precisely the emotions that the male has had to
    suppress in the service of achieving and
    maintaining his masculine identity (p.164).

  • Male socialization, Lisak contends, obstructs
    a males ability to respond sympathetically to
    both his own and other peoples distress i.e, it
    interferes with empathy. As he learns that
    vulnerable emotional states are unmasculine,
    and that they must be expunged from his
    experience lest he be forced to label himself
    unmasculine, the male is forced to respond as
    aggressively to his own internal displays of
    vulnerability as he would to those of others
    (p.166). This leads to a lack of empathy, which
    allows sex offenders to hold the attitudes
    tolerant of offending identified by Hanson and
    Harris (1998) as related to sexual recidivism.

  • D.Disturbances in interpersonal relationships
  • A fourth group of symptoms involve
    disturbances in interpersonal relations. The most
    profound and pervasive of these is an inability
    to trust (Hansons problems with intimacy),
    rooted in insecure attachment. Abused
    individuals experience fear and ambivalence with
    respect to interpersonal attachment and
    vulnerability. As closeness increases, they
    expect re-victimization, become more anxious, and
    may push others away or engage in behavior that
    sabotages the relationship. Because of the
    problems that result from past abuse and the use
    of dissociation to cope with it, they do not have
    a strong sense of inner guidance or a healthy
    template for interpersonal interactions.
    Consequently they do not read social cues well
    and make poor judgments about whom to trust.
    Some abuse survivors alternate between trusting
    everyone and trusting no one.

  • Abuse survivors may identify with the
    victim role, or, in an effort to fend off
    feelings of powerlessness, identify with the
    aggressor, increasing the likelihood that they
    will become perpetrators (Lisak, 1997). Their
    past experiences have often created faulty
    assumptions regarding the acceptability of high
    levels of aggression in relationships (Briere,
    1992). Moreover, past abuse and betrayal by
    adults fuel the excessive need for control that
    motivates many sex offenders. Survivors of sexual
    abuse may engage in indiscriminate sex because
    they believe that is their only value, or may
    avoid sex altogether. Survivors of abuse have
    distorted interpersonal scripts and blurred
    boundaries. They typically re-enact their
    interpersonal traumas with the therapist,
    intimate partners, and/or other group members
    (Briere, 1992 Courtois, 1988). Intimacy
    deficits which are a common long-term effect of
    childhood abuse, were found by Hanson and Harris
    (1998) to be related to sexual offense recidivism.

  • E. Somatization
  • A fifth group of symptoms are persistent
    physical symptoms that often defy medical
    explanation. The most common are digestive
    symptoms, chronic pain, cardiopulmonary symptoms,
    chronic pelvic pain, conversion symptoms,
    irritable bowel syndrome, headaches, acid
    stomach, and sexual dysfunction. Clinicians who
    have worked with sex offenders in inpatient
    settings are aware that they often have multiple
    ill-defined physical complaints which resist
    medical treatment. These complaints are not
    manifestations of hypochondria or a need for
    attention, but rather the long-term effects of
    repeated early traumatic experiences, which have
    compromised the bodys ability to cope with
    stress. Traumatized individuals have overactive
    sympathetic and parasympathetic nervous systems,
    which over time cause the body to react like a
    car that is constantly having the gas and the
    brakes applied at the same time. The body wears
    out prematurely under these conditions,
    explaining the findings of the Kaiser ACE study,
    which clearly linked a history of childhood abuse
    to the 10 leading causes of death (Felitti et
    al., 1998).

  • F. Disturbances in meaning systems
  • Finally, individuals with severe trauma
    histories often show disturbances in meaning
    systems, i.e., they fail to find meaning in the
    things which usually give life a sense of
    purpose. They are often alienated from any
    system of spiritual belief (How could God have
    let this happen to me?) and have an adversarial
    view that all human relationships are a power
    struggle and that everyone is out for himself.
    This may be accompanied by a profound sense of
    learned helplessness and a pervasive decreased
    sense of competency. Herman (1992) has observed
    that those who seem to recover best are those who
    find some over-arching meaning or activity
    related to the abuse, e.g., getting legislation
    introduced or changed, or speaking as a victim

  • Take Home Message 3
  • It makes no sense to stress the damage our
    clients have done to their victims, while
    ignoring or invalidating the damage done to them
    as children. An understanding of complex
    developmental PTSD is essential to effectively
    treat sex offenders.

  • Section IV. Processing Trauma
  • A.How trauma treatment works
  • What happens in trauma treatment and why it
    works is probably best understood from the
    perspective of a systematic desensitization
    paradigm. Humans are genetically programmed to
    want to affiliate, because this is something that
    has allowed the species to survive. Thus
    connecting with other humans is an innate drive
    that is rewarding at a neurological level. The
    relationship with the therapist(s), and in some
    cases with other group members, activates this
    innate drive, which leads to the effective
    counter-conditioning of negative thoughts and
    emotions from early experiences. This is thought
    to take place in 5 phasesExposure, Activation,
    Disparity, Counter-conditioning and Resolution.

  • Clients experience memories of earlier
    interpersonal trauma from various sources in
    treatmentprocessing the their own offenses or
    those of others, doing homework assignments such
    as writing an autobiography or timeline, hearing
    about the abuse histories of others (exposure and
    activation), and viewing victim empathy films.
    They expect that abuse or abandonment will happen
    if they delve into these memories, but in reality
    the situation is safe, unlike childhood. The
    therapist is not abusive, rejecting or otherwise
    dangerous (disparity). Clients experience
    positive emotional states (safety, affiliation,
    comfort, support, validation), which gradually
    diminish and begin to extinguish negative
    feelings and responses (counter-conditioning).
    Eventually, as these negative feelings begin to
    weaken, clients are able to become aware of how
    they have affected their lives, process them and
    develop more effective positive coping responses.
    These feelings may never disappear completely,
    but when they do re-surface, they no longer have
    the same destructive impact (resolution).
    Recovery from early abuse has been likened to a
    spiral, in which clients re-visit the same issue
    a number of times, each time viewing it from a
    different perspective, as their trauma processing
    proceeds (Sgroi, 1989).

  • The therapists personality is the most
    powerful tool in treatment. Linehan observed that
    the relationship with the therapist is the
    primary re-enforcer, although peers in the group
    may also be important. Because therapy triggers
    the attachment relationship, the clients
    attachment status will begin to emerge and become
    more observable in the clients reactions and
    behavior. Assessment should be an ongoing process
    and client reactions should be carefully
    monitored and explored in treatment. These
    reactions may include dependency, intrusiveness,
    a need to control or denigrate, fear and rage,
    and distortions of the therapists motives and
    behavior. While this may elicit extreme
    discomfort and strong counter-transference in the
    therapist, greater awareness of what clients are
    struggling with will enable therapists to provide
    a safe place where the past can emerge and be

  • Take Home Message 4
  • Research on what makes psychotherapy effective
    has consistently found that the relationship with
    the therapist is the most powerful and important
    variable. This has been largely ignored in sex
    offender treatment, as if sex offenders are
    different from all other clients. Therapy cannot
    be successful outside the context of human

  • B.Philosophy of trauma treatment
  • There is an innate tendency for humans to
    process trauma-related memories, moving toward
    more adaptive functioning. In trauma treatment,
    the clients personal experiences and perceptions
    form the basis for interventions, not the
    therapists theory or pre-conceptions. Briere
    (1992) has referred to this as the
    phenomenological approach, because the focus is
    on the clients individual experience. The client
    is viewed as adaptive, rather than mentally ill
    or defective. Symptoms and defenses are seen as
    accommodations to early victimization (survival
    strategies) and/or responses to the long-term
    effects of abuse. Re-framing is not merely empty
    reassurance. It is rather a totally different
    perspective, an alternative way of understanding
    the clients behavior, emotions and cognitions.
    (One mans cognitive distortion is another
    mans reality.) The goal of trauma treatment is
    not only symptom removal. Therapy must also focus
    on correcting distorted assumptions/core beliefs
    as well as other long-term effects of abuse.
    Symptoms serve a deep psychological purpose and
    therefore cannot be easily given up. Therapists
    need to understand the adaptive significance of
    symptoms in order to formulate appropriate

  • It is useful to explain the adaptive
    significance of some of the most serious
    symptoms, tension reduction behaviors (TRBs) such
    as dissociation, drugs, self-injury, eating,
    gambling and compulsive sex, also pointing out
    that people often rely on these because they have
    nothing else. Their affective overwhelm has
    prevented them from learning more effective
    coping skills. It is equally important to make
    clear that the feelings which trigger these
    behaviors must be accessed and processed because
    they continue to exert a destructive influence on
    the clients life and to distort his perceptions
    of others. This validation often provides relief
    for clients (Maybe Im not mad, or bad), giving
    them the support needed to go deeper. Rarely a
    client gets stuck at the level of merely
    excusing his behavior with I molest kids because
    I was molested. Rather than dismissing him as
    resistant and whining, it is more likely a
    sign that he is terrified and may not even know
    why. This may suggest a need for some individual
    contact, or simply backing off and letting him
    remain in the group until he feels safer.

  • Some examples of positive reframing of symptoms
    often seen in our clients that may help reduce
  • attention seekingbehavior designed to
    ensure proximity, or attachment seeking
  • callous, unemotionalavoidant/dismissive
    attachment, may be defensive rather than
    antisocial may indicate the presence of
    dissociation or learned fear of revealing real
  • Anxietylack of a sense of personal
    competence, lack of skills, failure to develop a
    sense of self-efficacy
  • Impulsive behavior or low frustration
    toleranceaffective dysregulation
  • Self-defeating behavior--may stem from a
    sense of not deserving, a fear of
    responsibility due to a sense of personal
    incompetence, or maladaptive learning
  • Oppositional behavior--may reflect
    unwillingness to trust authority because of early
    experience, or a need for control
  • Manipulation--failure to believe that others
    will meet your needs, a sense of powerlessness
  • Not hearing feedback--may feel threatened,
    not caring, because of past experiences
  • ResistanceWhat we call it when clients
    try to defend themselves from therapists
    mistakes (Briere)

  • Basic Principles of trauma treatment
  • 1.Provide and ensure safety
  • It is not necessary for the therapist to
    actively introduce trauma, because it will come
    up regularly in the normal course of treatment,
    for the reasons I have described. It is
    necessary for the therapist to anticipate it,
    recognize it, and know how to deal with it so
    that clients do not become frightened or
    overwhelmed. An important part of this is to
    establish a culture of treatment in the group
    so that the client will not perceive himself or
    herself, to be criticized, humiliated, rejected,
    dramatically misunderstood, needlessly
    interrupted, or laughed at during therapy and
    that boundaries and confidentiality will not be
    breached. The expectation should be that trauma
    issues will be honored and help will be offered
    by both therapist and other group members. The
    client will be supported, not ignored, isolated,
    or made to feel weird. Group members can play
    an important role to reduce the sense of
    isolation, offer support, and confront in a way
    that is caring rather than punitive. For many
    clients, this may be their first experience of
    intimacy that is not sexual.

  • 2.Provide ensure stability, both life
    stability emotional stability, through the
    initial use of DBT
  • 3.Maintain a positive consistent
    therapeutic relationship. Potential benefits,
    derived from research
  • Decrease treatment drop out and
    increase attendence (Rau
  • Goldfried, 1994)
  • Less avoidance greater client
    disclosure (Farver Hall, 2002)
  • Increased compliance w/ all forms of
    treatment including meds
  • (Frank Gunderson, 1990)
  • Greater openness to therapist feedback
    (Horvath Luborsky,
  • 1993)
  • Increased tolerance of painful thoughts
    and feelings (American
  • Psychiatric Assoc, 2001)
  • Hanson Therapist must be able to form
    a meaningful
  • relationship with offenders warm,
    empathic, rewarding. From
  • a trauma perspective, these qualities
    are necessary for counter-
  • conditioning to occur

  • 4.Treatment should be tailored to the
    individual client, by taking a thorough history
  • Treatment aimed at affect dysregulation needs
    to address which feelings are most difficult to
    regulate. Identify predominant schema
    self-perceptions as bad, inadequate, or helpless
    others as dangerous, rejecting, or unloving
    future as hopeless. Treatment may trigger
    abandonment, rejection, or betrayalclients may
    perceive the therapist as punitive, critical or
    abusive. It is useful to know that X has
    abandonment issues, Y perceives caring as
    intrusive or sexual, Z expects domination or
    hostility from authority figures. A detailed
    history should help to identify attachment style
  • 5. Work within the therapeutic window,
    (Briere) or window of tolerance (Badenoch),
    optimizing the clients ability to process
    painful material and avoiding emotional overwhelm.

  • 6. Take gender issues into account
  • Sex role socialization affects how trauma
  • experienced and expressed. There are
  • differences in symptoms behavior. For
    men, anger
  • is the only acceptable feeling likely to
    react with
  • compensatory hyper-masculinity,
    compulsive sex,
  • and/or identification with the
    aggressor. Women are
  • more likely to internalize feelings, men
    more likely to
  • externalize. Both may feel like they are
  • goods.
  • 7. Monitor counter-transference
  • It is important for therapists to be
    attuned to their own internal experience. Seek
    consultation with a colleague who understands
    trauma issues, and have a strong support system.

  • Techniques to help identify triggers
  • Does this feeling make sense? Appropriate to the
    situation? Too intense? With memories?
  • Was there an unexpected alteration in awareness?
    Has this previously occurred in a similar
  • Identify properties of trigger interpersonal
    conflicts, sexual situations or stimulation,
    interactions with authority figures, people with
    physical or psychological characteristics similar
    to perpetrator, boundary violations, sound of
  • Explain TRBs, construct an alternate strategy
    designed to decrease powerlessness increase

  • Cognitive interventions
  • Talking about trauma makes it more real,
    validates the clients feelings, makes the
    assumptions, perceptions beliefs that were
    encoded at the time more clear listeners bear
    witness, give feedback
  • Growing awareness of what could reasonably
    have been done--I shouldnt have let him.
    Clinician should refrain from making critical
    comments about perpetrators or trying to talk
    clients out of their perceptions. (Ex Susan
    Forward) Cognitive interventions are most
    effective when clients experience original
    trauma-related thoughts self-perceptions (e.g.,
    guilt, self-blame) with present logical
    perspective. Opposite of Relapse Preventions
    direct confrontation of thinking errors. This
    counters blaming or shaming stateme
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