Marc Goldman, MS & Brad Owen, MA
As our society becomes less tolerant of sexual crimes and more willing to publicly discuss some of the many relevant issues, the role of the support community for people with intellectual impairment must consider their role. While some debate important legal, ethical, residential, policy, human rights, and critical safety concerns, practitioners struggle to provide effective treatment for a group of individuals whom are often marginalized within their own support system.
The majority of significant developments in the treatment of sexual offenders have occurred over the past thirty years (Marshall & Serran 2000). Modern era treatment has moved from primarily consisting of behavioral techniques designed to suppress sexual expression (Griffiths, Quinsey, & Hingsburger 1989) to a treatment philosophy that requires treatment of multiple aspects of the individual's being. In the 1970's, aversive procedures were readily accepted as the treatment of choice for sexual offenders. Despite their popularity, there remains a lack of evidence that such techniques resulted in long-term change in sexual expression (Marshall, Anderson, & Fernandez 1999). An individual having developmental delay that had engaged in sexual expression that others considered "inappropriate" was vulnerable to institutional placement and behavioral suppression techniques. Griffiths, Quinsey, and Hingsburger (1989) noted that despite an understanding that the reduction of undesirable behaviors can most efficiently occur through the learning of desirable behaviors, such teaching rarely occurred when addressing aberrant sexual expression.
There are few studies of sexual offenders having developmental delay (Day 1997). Available research is descriptive and provides information that has implications for prevention as well as treatment. One survey and literature review reported that sexual offenders who have developmental disabilities exhibited more social skill deficits and were sexually naive (Tudiver, Brockstra, Josselyn, & Barbaree 1997). Day (1997) confirmed that poor interpersonal skills and a lack of sexual knowledge and experience was prevalent among sex offenders with intellectual impairment.
Day (1997) reported that "true sexual deviance is rare." Treatment interventions for individuals who are not deviantly aroused are expected to vary in at least some respects from those having paraphilias. Hingsberger, Griffiths, and Quinsey (1991) suggested that some individuals having developmental disabilities that engage in aberrant sexual expression are influenced by variables such as lack of appropriate interpersonal skills or sexual knowledge. Such "counterfeit deviance" might also be influenced by agency created environments and rules, lack of opportunity for sexual expression, and absence of agency policy, among other factors.
Although the reported percentage of increased risk varies as a result of experimental design, people having mental retardation are at greater risk of sexual abuse than the general population (Mansell & Sobsey 2001). Research has demonstrated that a higher than expected percentage of sex offenders were themselves sexually victimized (Knight & Prentky 1993). Although not considered the exclusive reason for aberrant sexual expression or an excuse, treatment of offenders who were themselves victimized should include assessment and treatment of their victimization.
Although there is a vital need for more research, available findings imply that sex education and development of social skills should be considered components of any program designed for prevention and/or treatment of offensive sexual behavior. The need for careful evaluation of the individual prior to designing treatment interventions is clear.
Determination of the likelihood that an individual will engage in aberrant sexuality in the future and understanding the circumstances that such behavior most likely would occur makes up the process of risk assessment. Although Doren (1999) submitted a list of 30 Risk Assessment instruments and Prentsky and Edmunds (1977) compiled over ninety instruments that are used by clinicians that work with sex offenders, there is no instrument that is clearly validated for use with people with developmental disabilities. Research on the actuarial scales that have been developed by Quinsey, Harris, Rice, & Cormier (1998) are in the early stage (Seghorn & Ball 2000).
Given the minimal amount of actuarial, or descriptive, data on offenders having developmental delay, clinical models of assessment are often used
(Johnston, 2002). Mikkelsen and Stelk (1999) provide an assessment model that includes taking into account multiple factors and warn that biases can result in an over or under estimation of risk. Their model assigns a numerical value to the intensity/ severity of the offense that takes into account the individuals actions and the resulting physical damage to the victim. The schema also considers frequency of criminal behavior and latency, or time since the previous offense. It reviews the context of the criminal behavior and the stressors that made the behavior more likely.
Bays and Freeman-Longo (1995) consider 29 factors to estimate Dangerousness for Offenders. These include static, or unchangeable variables such as history of offenses, anger associated with offenses, and the presence and number of paraphilia. The instrument also considers numerous variables that can change over time (dynamic factors) such as motivation for treatment and willingness to discuss the offense.
Given the lack of validated approaches to assessment of offenders and non-adjudicated people who are accused of dangerous sexual behavior having developmental disabilities, care should be taken to gather as much information as possible from the individual and collateral, prior to estimating risk. Assessment should remain ongoing, not only to obtain additional static information but, to also consider changes in dynamic factors that are subject to change as a result of environmental factors, and internal change as the result of mood or the effects of treatment.
Care must be taken to gather sufficient risk assessment information prior to providing community support for an individual whom has engaged in sexually aggressive behavior. When, where, and towards whom the individual is most likely to re-offend should be determined. The person's willingness to cooperate with supervision and comply with rules for community protection must be established through frank discussion with the individual. The residential provider and others in the offender's support network must take offense risk seriously and become willing participants in a network of support (Cumming & Ball 1997).
Treatment of sexually aggressive individuals having mental retardation is a relatively new field and treatment providers are "breaking new ground" (Haaven, Little, & Petre-Miller 1990). Research on the efficacy of treatment of individuals having developmental delay has been limited. Although broad treatment (and assessment) guidelines have been established by the Association for the Treatment of Sex Abusers and by the International Association for the Treatment of Sexual Offenders, none of the guidelines are specific to people having developmental disabilities (Langevin & Curnoe 2002). Practitioners are left to work within existing guidelines and prevailing approaches while considering necessary accommodations as well as applicability to a population about who little is known.
Current treatment approaches recognize that sexual crimes do not result from one variable. Rather, they result from a combination of influences including historical, socioeconomic, cognitive, behavioral, physiological, and social variables (Barbaree & Marshall 1998). Treatment includes addressing these multiple influences. A cognitive-behavioral treatment approach involves many components including teaching the offender his specific "cycle" of offending and developing new skills to avoid certain situations and cope with stressors. Complicating treatment further is the current understanding that sexual offenders are a heterogeneous group (Marshall, Anderson, & Fernandez 1999). Although these and several additional treatment practices are generally accepted, debate concerning which components are essential and for whom remains in question and await additional research (Marshall & Serran, 2000).
Haaven, Little, and Petre-Miller (1990) described an institutional program that treated sex offenders having developmental delay. They modified numerous cognitive behavioral treatments to maximize learning and used a variety of novel modalities to assist individuals in mastering numerous challenging concepts. Blasingame (2001) has published a very useful Manual that includes numerous unique approaches to teaching what many in the community of treatment providers of "normal" sex offenders consider essential components of treatment.
Adherence to Community Treatment and Community Protection
External control of dangerous sexual expression in "normal" sexual offenders is often the result of legal sanction. Lengthy probation with maximum suspended sentence is frequently ordered to provide community safety. Specific conditions of probation that include adherence to strict treatment requirements are the norm. Violations of those conditions can result in incarceration. Habitual offenders are likely to be incapacitated indefinitely. Community support for individual's having developmental delay and are at risk of sexually aggressive behavior is often complicated by the individual's lack of motivation for treatment. Many such individuals have faced few, if any, long-term community sanctions. Having the right to refuse or withdraw from treatment and/or support at any time, treatment providers must tactfully intervene to maximize safety. The nature of cognitive behavioral treatment demands discussing sexual and other thoughts and addressing behaviors that have been associated with intense emotions and unpleasant consequences. Individuals who feel comfortable with the treatment process are much more likely to be forthcoming in considering their behavior, thoughts, and motivation. They are likely to be asked to give up certain possessions such as pornography or behaviors such as the use of alcohol. While those under court supervision can be ordered to give up such rights in exchange for residing in the community, non-adjudicated individuals can only do so voluntarily.
Treatment of any challenging behavior often requires habilitation that includes the development of internal controls. The individual develops skills to cope with stressors that have historically resulted in the person engaging in challenging behaviors. Until such skills or internal controls are developed, environmental and/or external controls are often used to provide a measure of safety for the individual and community.
The Blue Ridge Center Program
The Blue Ridge Center is a Mental Health Center that serves four Counties in Western North Carolina. The Center's Developmental Disabilities Services Program provides the support for individuals at risk of sexually aggressive behavior. Along with their other responsibilities, the Crisis Supports Coordinator, two psychologists, and student interns provide the services for those at risk. People in the program all receive case management support and the Center's psychiatrist treats many of the individuals for psychiatric disorders. Treatment services are determined following assessment and include group and/or individual treatment.
Because the court has adjudicated very few of the program participants, the Blue Ridge Center relies on novel means of implementing external controls. Treatment holds each individual accountable for their own behavior and often includes firm feedback and voluntary restrictions. At the same time, treatment must be provided in a manner that motivates the individual to remain involved and must be fun and rewarding. The treatment teams are challenged to support these non-adjudicated individuals and develop structured external controls that include, but are not limited to:
"voluntary waiver of pornography, alcohol, and drug use,
"voluntary "danger zone" restrictions to restrict the individual from high risk situations,
"permission to search the individual's personal space for contraband
"and other revocable client and community safety structures.
While some of the individuals in the Blue Ridge Program reside in group settings with high levels of supervision, others live in situations where minimal support is provided.
The Blue Ridge Center model requires both direct contact and supervisory staff supporting people at risk of sexual aggression to be trained in sex offender treatment philosophy, function, and practice. Semi-monthly team meetings with community provider supervisory staff affords opportunities for additional training and also address client specific issues. Community direct-care staff meets in monthly group clinical supervision, in addition to their agency meetings, to review interventions and discuss the stressors and accomplishments of their work. The extremes of direct-care staff burnout or counter-transference are addressed at these meetings, and if indicated, passed on to supervisory staff for review. Supervisory staff has their own semi-monthly Consultation Team meeting. Attendees include but are not limited to: group home managers, program directors, shift supervisors, Qualified Developmental Disability Professionals, Alternative Family Living providers, guardian and/or probation officer when involved, vocational supervisors, and at times direct-care staff. After signing a confidentiality agreement, each program representative gives a client/case review and a staff intervention review. Agency policy issues invariably arise and are either developed in the meeting or tabled for agency approval. Supervisors are trained to augment staff support, and outpatient group materials are evaluated for their effectiveness and applicability in their program. Where indicated, the Consultation Team makes recommendations for program changes to community staff. At times, the Consultation Team must address funding, community and vocational placement, and other administrative issues that impact the treatment process.
Prior to participation in-group treatment, one of the group facilitators interviews the individual along with the individual's Lead Clinical Support (LCS) person. Both are informed of the general purpose and function of the outpatient group. The LCS person and client attend all sessions together. During the weekly ninety-minute sex offender specific group, group rules, norms, and assignments are taught, discussed, and frequently reviewed. The Lead Clinical Support person supports the individual by helping him to read, write, draw, understand, practice, and otherwise bridge the developmental delays without demeaning, coddling, or answering for the client. The group facilitators teach material and assign homework to both LCS person and client. The Lead Clinical Support person informs residential staff about the group material and homework and assists the individual in reviewing material and practicing skills. The LCS person meets outside of the group with the individual between one and several times per week.
Group members maintain a daily diary of their mood and complete a self-evaluation of their perception of their participation in the group. They also complete a Weekly Check-In Report in which they indicate if they have followed specific treatment guidelines, experienced "wrong sex thinking," and report angry emotions and behaviors experienced during the previous week. The Lead Clinical Support person assigned to the individual completes a weekly checklist (Weekly Support Provider Report) that includes incidents of aberrant sexual behavior or precursors to such and a daily mood evaluation. Additional homework involves practicing skills taught in the group and reviewing information discussed in the group.
Each group session begins with a review of each group member's completed homework as well as review of the Weekly Support Provider's Report. Participants then review previous material and skills that they have been taught and new material is usually introduced. Teaching is accomplished through a variety of modalities including discussion, practice, and role-plays. Following a brief snack-break the remaining time is usually devoted to activity and process therapy designed to strengthen learning of previously presented material and increase social bonds within group members.
As the group progresses, Dialectical Behavior Therapy (DBT) Module activities modified for individuals with disabilities are taught. Skill areas such as relaxation, mindfulness, interpersonal effectiveness, emotional management, and distress tolerance are presented. Both client and LCS persons practice the skills. Social skill development and sex education are ongoing issues that are discussed regularly in the group.
As the group process matures, "Brag Time" and "Safety Violations" will be included in the process portion of each session. "Brag Time" affords clients time to brag about the skills they used that improved their relationships, and kept themselves and others safe. "Safety Violations" are lapse and relapse disclosures. Once taught, clients are encouraged to not only disclose, but see a DBT-style Chain Analysis of the decisions, feelings, and actions constructing and triggering the lapse or relapse. Group members are expected to provide non-judgmental feedback steeped as much as possible in disclosures of how they have dealt with similar situations. Also included in the process portion of group are role-play, reenactment, internal voicing and chorus, movement, imagery, social situation drama, and other gestalt-style techniques.
Participants in the program are assigned an individual therapist who is comfortable with waiving confidentiality to inform clinical and non-clinical team members about a client's long-term clinical issues, therapy interfering behaviors, and/or increasing risk of re-offense. The men who attend the treatment group are also seen in individual counseling sessions. The time is used to review group material or introduce additional information. Many individuals are treated for their own victimization during individual sessions. The sessions are also used to provide sex education and social skills training. The LCS person also attends the individual sessions.
The relatively new field of treatment of individuals having mental retardation who have engaged in sexually aggressive behavior is lacking in research at this time. Treatment is based on modification of methodology used to treat sexual offenders of normal abilities and is comprehensive. Research does seem to imply that social skills training, relationship/sex education, and treatment of victims might prevent aggressive sexual behavior and should available for all individuals. Novel approaches are required to foster motivation and to induce those at risk to voluntarily relinquish rights in order to maximize safety. Individuals in treatment have multiple needs and require support well beyond the therapy session in order to develop skills to assist them in refraining from re-offense. There is an important need for support providers to provide resources and develop services for sexually aggressive individuals with mental retardation who reside in the community as well as provide prevention programs for all individuals.
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Tudiver, J., Brockstra, S., Josselyn, S., & Barbaree, H. (1997). Addressing needs of the developmentally delayed sex offenders: A guide. Toronto: Clark Institute of Psychiatry.
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