Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory

Transcription

1 Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory Tennessee Sexual Offender Treatment Board Annual Training Conference Nashville, Tennessee Monday August 6, 2007 Presented by Phil Rich, Ed.D., LICSW Clinical Director, Stetson School, Barre, Massachusetts (978/ x114)

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3 Understanding and Applying Attachment Theory to the Treatment of Juvenile Sexual Offenders An Attachment-Informed Perspective An attachment-informed perspective has recently and increasingly been introduced into work with both adult and juvenile sexual offenders, representing a significant shift away from both manualized and strictly harm reduction or containment models of sex offender treatment. This attachment-informed work emphasizes the connections and relationships between individuals and important early figures in their lives, and how these early relationships set the pace for and influence the development of social interactions, relationships, and behaviors throughout life, including the development and maintenance of sexually abusive behavior. In an attachment-informed model, treatment is not simply about psychoeducational and cognitivebehavioral modes of instruction and treatment. It is also, and perhaps more critically, reflective of the manner in which we think about and understand juvenile sexual offenders, the way we interact with and relate to them, and the way in which we come to conceptualize what juvenile sexual offenders need in treatment. Attachment Difficulties and Sexual Offending Of particular note, even though attachment theory is a theory of childhood development, over the past few years it s become increasingly common to link disturbed or under-developed early attachment relationships to the later development of pathology. In our field, there s an increasing assumption that disturbed or insecure attachments exist in sexual offenders, with an almost implicit supposition that the onset and maintenance of sexually abusive behavior is fueled by what we might call "attachment deficits." Ideas related to the development of attachment that appear in the general criminological literature are largely limited to explanations of causal pathways and factors contributing to criminality, with attachment needs implicated as both a historical (static) and a criminogenic (dynamic) risk factor. In this formulation, poor, or suboptimal, early attachment experiences serve as a historical risk factor because they set the pace for and begin to define the developmental pathway along which dysfunctional and antisocial behavior may later develop, disconnected from the needs of other people or society as a whole. Attachment Difficulties and Sexual Offending In turn, failure to meet attachment needs in early childhood, or the intrinsic need to feel secure (the static risk factor), combines with, is potentiated by, and itself influences other risk factors that later appear along the developmental path. Emerging developmental risk factors may drive antisocial behaviors as the individual struggles to meet personal needs. Some of these early risk factors are changeable, and are thus dynamic. However, some of these will harden and themselves become static risk factors, embedded into the developmental experiences of the individual, whereas other risk factors will remain subject to influence and change, remaining both stable and dynamic over time. For some individuals, when combined with other risk factors, early attachment experiences serve as both a static risk factor and also as a dynamic, but stable, risk factor when attachment difficulties and insecurities continue as the individual ages into adolescence and later adulthood. It is thought that the combination of risk factors, with attachment deficits driving both static and stable dynamic risk, serves to catalyze antisocial behaviors in some individuals, and in some cases, sexually abusive behavior. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 1

4 Attachment Difficulties and Sexual Offending However, despite the attractiveness of such a theory, there s little evidence that the existence of attachment deficits has any direct connection to the onset of sexually abusive behavior Hence, as we struggle to both understand the development, onset, and maintenance of sexually abusive behavior and how best to treat that behavior, it s important to not simply accept ideas that are intuitively appealing, but also struggle to understand how to apply ideas, as well the boundaries of those ideas, with respect to ideas about treatment. If taken alone, we see that attachment difficulties are not a sufficient factor to serve as a direct link between early experience and the later development of criminal or sexually abusive behavior, and attachment deficits have not yet proven to be significant in distinguishing or explaining sexually abusive behavior or distinctions between non-sexual antisocial (or delinquent) behavior and sexually abusive behavior. Attachment Difficulties and Sexual Offending Nevertheless, although different studies have arrived at different conclusions, sometimes somewhat at odds with one another, it generally seems clear that there are differences in the strength or pattern or experience of attachment security between a criminal population, including sexual offenders, and a noncriminal population, in which we recognize a far greater incidence of insecure attachment among criminals than the general population. However, patterns, styles, or strength of attachment have not proven sufficient to distinguish between subtypes of criminal offenders, and have not been sufficient to consistently or adequately discriminate between non-sexual criminal offenders and sexual offenders, nor among sexual offenders. In fact, although attachment difficulties do appear related to functional difficulties, they nevertheless do not appear to be a sufficient cause for any kind of troubled or antisocial behavior, although they may well be a common, and perhaps even, necessary element. Three Risks in Assessing Attachment Deficits in Juvenile Sexual Offenders Aside from limitations in adult sexual offender research, attachment research in adolescent sexual offenders is even more rare than the relatively sparse research into attachment in adult sexual offenders. We face three risks, if we draw our conclusions on the current research and theory. Risk One. Failure to Discriminate Between Adult and Juvenile Sexual Offenders. Risk Two. Failure to Discriminate Among Juvenile Sexual Offenders. Risk Three. The Uncritical Acceptance of Ideas. The Basis of an Attachment-informed Perspective From a treatment perspective, attachment-informed work means developing a view of individuals and their needs which is informed by attachment theory. Attachment theory is not a theory of pathology. Instead, it is a theory of childhood development in which the concept of attachment is a complex construct that significantly contributes to the way in which we come to experience the world in which we live, and in which we engage in transactions and interactions with others. Attachment theory defines the processes by which we form mental representations of ourselves and of others, develop beliefs and expectations about social interactions and relationships, and build the basis for our social behaviors. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 2

5 Working Definitions: Attachment As we use it, "attachment" generally describes the sense of social connection that one individual has to another, and the sense of social relatedness or belonging that an individual has to a larger reference group. Indeed, it may be that as it develops into adolescence and adulthood, "attachment" is really just another way of describing deeply rooted social connectedness, and the capacity for such relatedness. Here the emphasis is on deeply rooted. On this note, Hirschi (2002) writes that the bond of affection for conventional persons is a major deterrent to crime ( p.82 ), and notes that we are moral beings to the extent that we have internalized the norms of society, and that the essence of internalization of norms, conscience, or superego lies in the attachment of individuals to others (p. 18). Working Definitions: Attachment Attachment includes relationships that involve primary attachments, other relationships that involve affection and intimacy, and relationships that are more generally affiliative, as well as a more pervasive sense of belonging to a larger social group. Each of these relationship types involve an emotional bond of some kind, and demonstrate a sense of and capacity for social and emotional connection. Working Definitions: Confident and Secure Attachment If "attachment" refers to a sense of social connection, social relatedness, and an emotional bond, then we can consider secure attachment to lie in a sense of trust in others who are experienced as consistently available, reliable, caring, and trustworthy. In turn, this contributes to a sense of self as capable and worthy, with the capacity to engage in meaningful relationships with others. This form of attachment, which we typically call secure, reflects optimal attachment experiences, in which the sense of self and others is characterized by confidence. Working Definitions: Disordered Attachment Disordered attachment implies, not an absence of attachment, but a sense of attachment that is strained, tenuous, uncertain, and in which there is uncertainty about and lack of confidence in the capacity of others as reliable, capable, and caring. In this context of suboptimal attachment experiences, others may be viewed as untrustworthy and relationships viewed with caution, and the self experienced as unworthy, incapable, and ineffective. The sense of self and others is tenuous and uncertain, fueling difficulties in self-image and the capacity to understand, trust, or perhaps care about, others and form social relationships. In turn, these difficulties may translate into many different types of cognitions, emotions, and behaviors, driven by a suboptimal, limited, and possibly damaged emotional bond and sense of belonging. Working Definitions: Attachment Deficits Attachment deficits, related to a disturbed or disordered attachment, represent a limited ability to form meaningful and satisfying relationships, engage in intimacy, develop the skills to understand others, and engage in the behaviors, interactions, and relationships that are required to acquire what Thakker, Ward, and Tidmarsh (2006) have referred to as human goods. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 3

6 Attachment Disorder or Disordered Attachment? As a psychological construct, attachment not only describes our sense of connection to others and our social behaviors, but also serves as a strong organizing frame for understanding human development and behavior, including the development of criminality. However, it s important for clinicians to have a clear understanding of attachment theory if they are to consider people they assess or treat meaningfully from this attachment-informed perspective. This is especially true as the use of attachment labels becomes more prevalent in our work, and particularly if the use of diagnostic labels like reactive attachment disorder, or pseudo-diagnostic labels like attachment disorder, become widespread. Without such understanding, we risk losing sight of what the construct of attachment is all about, as well as its implications for clinical work. Attachment Disorder or Disordered Attachment? The major difficulty with models that propose attachment disorders in older children and adolescents is that they are so broad as to not have useful diagnostic value at all. They use the term attachment disorder so broadly as to render it purely descriptive or so all inclusive that it subsumes virtually all other disorders. In fact, the range is so broad that, attachment disorder diagnosis or not, it suggests that the cause of almost all emotional and behavioral problems in children is impaired attachment. The attachment disorder therefore becomes a "shotgun" diagnoses, hitting all symptoms in its path. As Michael Rutter and Thomas O'Connor (1999) have written, if so many behavioral and psychiatric disorders are linked to attachment insecurity, then a diagnosis of attachment disorder loses its ability to explain much. Attachment Disorder or Disordered Attachment? In fact, there are no widely accepted diagnostic systems in place to diagnose attachment disorders in older children, adolescents, or adults. The only widely accepted diagnostic systems that recognize attachment disorders are applied when evident in children younger than age 5. The term attachment disorder, therefore, has no broadly agreed-on or precise meaning... officially, there is no such disorder (Chaffin et al, 2006, p. 80). Prior and Glaser (2006) note that sadly, this abundance of usage of the term (attachment disorder) appears not to be matched by an abundance of understanding as to what it means (p. 184). They write that the broad label of attachment disorder is not discernibly related to attachment theory, is based on no sound empirical evidence and has given rise to interventions whose effectiveness is not proven and which may be harmful (p. 187). Attachment Disorder or Disordered Attachment? The APSAC (American Professional Society on the Abuse of Children) Task Force notes that some clinicians apply the diagnosis of Reactive Attachment Disorder of Infancy or Early Childhood to children who do not meet the criteria. Consequently, in practice, a child described as having RAD may actually fail to meet formal diagnostic criteria for the disorder, and consequently the label should be viewed cautiously (Chaffin et al, 2006, p.81). The Task Force cautions clinicians to remain cognizant of... diagnostic uncertainties so that the diagnosis of attachment disorder is not improperly reified and more precise validity sacrificed (pp.81-82). Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 4

7 Attachment Disorder or Disordered Attachment? It is when "disordered attachment" is used descriptively, rather than as a diagnosis, that it serves an important and instrumental role in pointing to the function of earlier attachment and related social experiences in the development of current cognitions, affects, and behaviors. An Essential Understanding of Attachment Of particular note, attachment theory is unlike other theories of psychological development, because it essentially defines attachment as a primary biological process, and only later a psychological experience. Accordingly, attachment theory is truly a biopsychosocial theory built upon a number of essential ideas about attachment, which include at least six basic ideas. 1. From infancy through early childhood, the fulfillment of attachment needs builds an internalized and increasingly permanent sense of safety, hard wired into the central nervous system. 2. Through the nature and quality of interactions with early attachment figures, the child discovers and learns about itself and others. 3. Through these early relationships, ideas and beliefs about self and others are internalized and embedded in emotional and cognitive schema that form the basis for beliefs, interactions, relationships, and behaviors. This includes the way in which the child eventually 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 eventually in mental representations of self (self-efficacy, self-agency, and self-confidence) and others (the ability to depend upon others). 5. Through attachment experiences, children develop the capacity for self-regulation, mediated through the responsiveness, attunement, and behavior of caregivers, and individuals who fail to develop a sufficient capacity for self-regulation continue to engage in insecurity driven behaviors. 6. Attachment patterns built early in life are relatively enduring, and provide an important foundation upon which all future social interactions and relationships are built. An Essential Understanding of Attachment Attachment is essentially about feeling secure and the development of security, imbued through early experience, captured and defined in internal representations, and recapitulated through scripts, plans, and automatic thinking and expectations. Early attachment experiences thus become the platform upon which later relationships are built and experienced, shaping social behavior, including social interactions. Early attachment processes can be understood as the framework upon which personality is built, serving as the source of both self-image and human connection. Internalized representations of early attachment experiences contain mentalized conceptions of relationships and what one can expect from them, and what one can expect from other people. They also provide the basis for critical social behaviors that include goal establishment and accomplishment, focus and self-regulation, and social interactions and relationship building. The operationalization of attachment theory provides a structure by which to develop insight and understanding into the cognitive and emotional psychology of both development and everyday life. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 5

8 An Essential Understanding of Attachment Clients continue to see themselves, the world, and others as a function of their experiences in early relationships, despite much evidence to the contrary. This anachronistic world view is mediated through the power of negative learning through the early development of the social brain, and is resistant to change. Self-concept is an emotional and conceptual spin-off of the self experienced in a relationship; in other words, the individual begins to emerge from the dyad. The core sense of the self, world, and others generated from early experience affects all domains of life... (Magnavita, 2006, p.889). The Basis for an Attachment-informed Perspective These essential ideas provide the basis for an attachment-informed perspective and understanding of an attachment-informed treatment environment. And, as we consider attachment theory and all it has to offer as a model of human development, it s useful to apply it as both a framework by which to understand the structure upon which human emotion, thought, and behavior is built, and as a lens through which to examine emotion, thought, and behavior in action. From this viewpoint, attachment-informed work means developing a view of individuals and their needs informed by attachment theory, recognizing that attachment theory is not a theory of pathology. Instead, it is a theory of childhood development in which the concept of attachment is a complex construct that significantly contributes to the way in which we come to experience the world in which we live, and in which we engage in transactions and interactions with others. Attachment theory defines the processes by which we form mental representations of ourselves and of others, develop beliefs and expectations about social interactions and relationships, and build the basis for our social behaviors. From this perspective, behind human behavior lie emotional and cognitive schema embedded into a mental map which itself is neurologically configured and hard wired, activated by biologically established and instinctual drives. The Basis for an Attachment-informed Perspective As a model of treatment, an attachment-driven approach to treatment is quintessentially psychodynamic in that it addresses the development of affect, cognition, and behavior, and ultimately personality and relationships, through dynamic and interactive psychological processes that are both internal (intra-psychic) and external (through social interaction). This triad of affect, cognition, and behavior essentially defines who we are, including our experiences and interactions in social relationships. From this perspective, attachment theory offers a backdrop against which clinicians can understand how individuals construct and deconstruct their world, and thus act upon the world in ways shaped by the emotional and cognitive images they hold of that world and the people in it, and mental representations of themselves and how they should behave. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 6

9 An Essential Understanding of Attachment: The Role of Metacognition The development of metacognition is considered one of the essential social skills linked to early attachment experiences, involving the capacity to recognize, understand, and reflect upon one s own thoughts and feelings and the thoughts and feelings of others. Fonagy (2001, 2004) asserts that the capacity to adequately mentalize evolves out of the attachment experience and the child's opportunity to observe and explore the mind of the caregiver, and that severe deprivation undermines the acquisition of metacognition. He describes poorly metacognition contributing to antisocial behavior in four ways, each of which are linked to the under-development of an agentive mind. In his formulation, crimes are committed by individuals with inadequate mentalizing capacities who engage in pathological attempts to adapt to a social environment in which mentalization is essential. An Essential Understanding of Attachment: The Role of Metacognition 1. Mentalization is intrinsically connected to self-awareness and the formation of personal identity. Therefore, those with limited reflective skills and a reduced ability to envision the mental states of others will also have a less well-established sense of their own identity. This reduces the capacity of individuals to recognize and be in touch with their own thoughts, and therefore accept responsibility for their behaviors. They "may more readily feel that they are not responsible for their actions because they genuinely lack a sense of agency." 2. Reduced capacity for mentalization may lead to a failure to anticipate or appreciate the consequences of personal behavior to the victims of such behaviors. 3. Reduced capacity for mentalization may contribute or lead to devaluing or dehumanizing potential or actual victims. 4. Limited metacognitive skills may lead to the easy deconstruction and reinterpretation of representational systems, including ideals and values, and thus allow antisocial behavior to be experienced in a self-serving manner by the perpetrator as appropriate and acceptable. Attachment and Juvenile Sexual Offenders Miner and Swinburne-Romine (2004) found that juvenile sexual offenders who molest children have fewer friends, feel more isolated, associate with younger children, and have more concerns about masculinity than other juvenile sexual offenders or non-sexual juvenile offenders. They do not consider juvenile sexual offenders to be more rejecting of social relationships than non-sexual juvenile delinquents, just less competent, and believe that there is a link between attachment, social isolation, and sexually abusive behavior. Juvenile sexual abuse appears driven by socially isolated, normless behaviors rather than by aggression, at least in those who molest children. This mirrors the conjecture of Hudson and Ward (2000) that sexually abusive behavior among adults is often more connected to the need for social connection and the acquisition of social goals than deviant sexuality. Juvenile Sexual Offenders and Social Connection Miner and Crimmins (1997) report that although juvenile sexual offenders do not differ significantly than non-sexual juvenile delinquents in either attitude or behavior, they were significantly more isolated from family than non-delinquent youth and more socially isolated from peers than violent delinquents. Miner points to the importance of peer relationships in adolescent healthy and well adjusted behavior, the possibility that juvenile sexual offenders expect adult and peer rejection, and the centrality of attachment difficulties in the development of sexually abusive behavior. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 7

10 Juvenile Sexual Offenders and Social Isolation Miner and Munns (2005) compared differences in attitudes, normlessness, and social isolation among juvenile sexual offenders, non-sexual juvenile delinquents, non-delinquent adolescents. They found no differences among the three groups on conventional attitudes or family normlessness, and although juvenile sexual offenders experienced more social isolation in school and in their families than non-sexual delinquents, they again did not differ significantly from non-sexual juvenile delinquents. Overall, consistent with other research, they found that sexual offenders are quite similar to non-sexual juvenile delinquents. Juvenile Sexual Offenders and Social Isolation However, Miner and Munns report that juvenile sexual offenders feel more isolated from their peers than non-sexual juvenile delinquents. They conclude that juvenile sexual offenders experience a deeper level of social isolation than non-sexual juvenile delinquents and non-offenders, and suggest that the inability to experience satisfaction in social relationships may turn some adolescents to younger children to meet sexual and social needs. Juvenile Sexual Offenders and Younger Victims In fact, based on data gathered through the National Incident-Based Reporting System (NIBRS), most juvenile sexual offenders victimize younger children, rather than peers or adults. Based on data, only 4% of all sexual assaults against adults were perpetrated by juveniles. Juvenile sexual offenders perpetrated 27% of all sexual assaults against adolescents, 39% of assaults against children aged 6-11, and 40% of assaults against children below the age of 6. 58% of all sexual offenses committed by juveniles were perpetrated against children below the age of 12, 38% against adolescents, and less than 6% against adults. Percentage of Total Sexual Offenses Committed by Juveniles All Offenses Against Adult Victims Offenses Against All Juvenile Victims (0-17) Offenses Against Victims Age Offenses Against Victims Age 6-11 Offenses Against Victims Age 0-5 % of Total 23.2% 4.0% 33.0% 27.0% 39% 40.0% Snyder (2000) Targets of Juvenile Sexual Offenders, By Age Adult Victims Juvenile Victims of any Age (0-17) Adolescent Victims (12-17) All Child Victims (0-11) Age 6-11 Age 0-5 % of All Offenses Committed by Juveniles (7-17) 5.7% 96.0% 38.2% 57.9% 33.8% 24.1% Based on Snyder (2000) Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 8

11 An Attachment-informed Approach to Treatment Attachment theory offers a broad view of human functioning that can change the way clinicians think about and respond to their clients An attachment perspective can add to the way that clinicians experience and listen to the stories of their clients and understand their behaviors. With respect to its use as a framework for treatment, rather than a theory of human development, the application of attachment theory to forensic mental health brings with it a client centered, and even psychodynamic, approach. Understanding, assessing, and treating dysfunctional and antisocial behaviors, including sexually abusive behaviors, looks to the mindset that produces the behavior or, at least, contributes to it, as well as the relationships that may have shaped criminal behavior and those that may sustain desistance from it. Ultimately, attachment theory considers not just social relationships and interactions to be central, but more significantly the core emotional and cognitive schemas behind behavior and relationships, and the development of capacity to engage adequately and appropriately in the social world. An Attachment-informed Approach to Treatment An attachment perspective can help define the treatment relationship between clinician and client, as well as the actual modes, techniques, and interventions of treatment. However, understanding the nature and dynamics of attachment informs rather than defines clinical thinking, and we should not assume that defined attachment styles of patterns can be simply superimposed onto clinical phenomena. In practice, many of the clients seen in clinical practice show both avoidant and ambivalent patterns at different times and in different circumstances (Holmes, 2001), and it does not make sense to think of clients in terms of single, mutually exclusive attachment classification. "In the same way that diagnosis serves as a guide (but not a recipe) in the treatment situation, notions of attachment organization provide a therapist with metaphors for thinking about early patterns of affect regulation and defense" (Slade, 1999, p. 585). An Attachment-informed Approach to Treatment Although attachment theory doesn t aim to describe criminality in particular, we recognize that attachment difficulties contribute to all sorts of functional problems and contribute to troubling behaviors, dissatisfaction with relationships and social life, and inability to meet goals or feel satisfaction, as well as inhibiting the development of metacognition, self-agency, and self-regulation, all key elements in the formation of criminal behavior and key in theories of criminality. An Attachment-informed Approach to Treatment From another perspective, social competence is of particular importance, not simply to feel socially adequate and socially connected, but also to tolerate emotional uncertainty and discomfort and modulate our behavioral responses when it s not possible to meet personal needs. This capacity for self-regulation, from the attachment perspective, is initially learned through the early external regulation of our primary caregivers, and is heavily implicated by Gottfredson and Hirschi (1990) in their general model of criminology, in which they assert that at the heart of all criminal behavior lies a lack of self-regulation. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 9

12 An Attachment-informed Approach to Treatment Rather than following a prescribed model of attachment therapy, clinicians will use an attachment-informed framework against which treatment interventions are applied, with attachment as a target of treatment. From this perspective, we search for causes and explanations for current behavior, at both the psychodynamic and cognitive level; we seek an understanding of the transactions and interactions between the internal mentalized world and the external physical world in which we recognize social relationships as the outcome of this interaction, driven by emotional and cognitive processes. For the therapist focusing on building attachment and a more secure mental map (internal working model), interactions and behaviors are understood through an attachment lens. Not surprisingly, in attachment-driven clinical work it is not the techniques we use, but the client s experience of therapy and of us, the environment in which treatment takes place, and how we aid their learning and sense of connection that is most significant. The Therapeutic Relationship and Positive Psychology As attachment theory is essentially a psychodynamic and interactional model, the therapeutic relationship comes squarely back into the foreground in attachment-informed therapy. Although cognitive-behavioral work is important in sex offender specific treatment, and will undoubtedly remain central to any sex offender specific treatment program, the therapist uses interactional techniques imparted through the therapeutic relationship. It is through this relationship, as well as other techniques and practices of treatment, that a treatment environment and alliance is established that can help re-build attachment and social relatedness. Ultimately, the emphasis in an attachment-informed therapy is on the development of an understanding, supportive, and caring relationship, marked by attunement between the therapist and the client, or a working treatment alliance. The Therapeutic Relationship and Positive Psychology In addition to the centrality of the therapeutic relationship and its treatment alliance, also connected to an attachment-informed perspective on treatment are elements of positive psychology. Here, we recognize that people have strengths upon which they can build in making improvements in their lives and are motivated, not just to avoid recidivism (an avoidance goal), but to accomplish desired and valued outcomes ( approach goals). Whereas avoidance goals have long been a central feature in the treatment of sexual offenders and involve voiding a behavior, approach goals are more synchronous with achievement and improvement. Attachment and the Good Lives Model These elements of therapeutic relationship and the pursuit of positive goals are clearly emerging in our work with both sexually abusive youth and adult sexual offenders. The Good Lives model, which is designed to work with adult sexual offenders, but also finding a place in work with sexually abusive youth, shifts treatment in focus from a containment and control model to a model of positive psychology. In this model, treatment works towards recognizing the identity, values, and beliefs with which the offender identifies so that he can work towards personal fulfillment and the development of prosocial social skills. The focus is not solely upon risk reduction, but also on enhancing the capacity of the offender to improve his life. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 10

13 Attachment and the Good Lives Model Thakker, Ward and Tidmarsh (2006) write we propose that the key theoretical perspective that guides treatment should be that of human well-being (i.e., good lives), rather than risk management, or relapse prevention (p. 324). They assert that the focus of treatment should be on identifying obstacles to accomplishing human goods and the acquisition of the capacities and competencies required to achieve human goods in ways that are socially acceptable and personally satisfying. Here, human goods are those aspects of social experience, life, and experience that the individual perceives as desirable. In the good lives model, individuals are regarded as active, goal-seeking beings whose goals are the acquisition of primary human goods. Yates (2005) notes that the aim in treatment is not to change the goal of social success, but to target the means the individual uses to achieve this goal. Treatment as Rehabilitative and Re-Constructive Without reference to cure, and beyond containment and risk management (which will remain central goals), treatment for sexual offenders is about rehabilitation. The goal is to change direction and rehabilitate attitudes, ideas, and behaviors that may be generally ineffective or antisocial, self-destructive, or harmful to others. In treatment, we seek to understand the source and the basis of problematic interactions and behaviors, and rehabilitate the mental maps and cognitive schema that underlie and are essentially responsible for such problems. Treatment as Rehabilitative and Re-Constructive Accordingly, the focus of the good lives model involves the identification of prosocial goals and strategies to achieve these goals, rather than on solely avoiding problematic or high-risk situations (Yates, 2005). Hence, Ward and Stewart (2003) assert that the focus on a good life, rather than risk containment and harm reduction, will contribute to the reduction of risk and the protection of society. Further, the expectation is that a focus on the acquisition of social skills and a personally fulfilling life will increase the offender s motivation to engage in treatment, and enhance the ability of clinician and offender to work together as partners, thus strengthening the treatment alliance. Empathy in the Attachment-Based Treatment Environment Empathy dissolves alienation, allowing those who feel empathy for others like "part of the human race" (Rogers, 1980). It allows those who experience empathic understanding to feel valued, cared for, and accepted. These are the very qualities that we wish to instill, develop, or unlock in the treatment of sexual offenders. They are also the same qualities that sexual offenders must experience from others in their environment, whether in their own homes or in the therapeutic relationship. Accordingly, we recognize that being the subject of empathy is the first step in the development of the capacity to be empathic. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 11

14 Empathy in the Attachment-Based Treatment Environment Rogers writes that people learn to become empathic by being with and learning from empathic people. This means having the experience of being understood by another person. In a model of early attachment, this means parents and this is certainly in keeping with ideas about attachment and early child development proposed by Schore (1994, 2001), Stern (2000), Siegel (1999) and others who write of the attunement, connection, and understanding that exists between infant and mother. We recognize empathy, then, as a requirement for socially connected human experience in which one is seen, understood, and cared for by others and in turn is able to see, understand, and care about others. Warner (1997) describes empathic understanding as crucial in therapy with clients whose ability to contain and process their own experiences has been weakened due to empathic failures in their early development. Empathy in the Attachment-Based Treatment Environment The therapist's empathy is curative and develops and strengthens the client's own capacity to relate to others. In fact, it is generally believed that the capacity of treatment staff to recognize and empathically respond to distress in the client influences the development of empathy, clarifying once again that the attachment experiences and elements we wish to develop in sexual offenders are dispositional in their interactions with others before they become dispositional in them. In teaching empathy, then, it is the therapist and treatment staff who must demonstrate empathy, described by Fernandez and Serran (2002) as integral to the therapeutic relationship. Manualized Treatment and the Therapeutic Relationship Which takes us back to the centrality of the therapeutic relationship and its role, even in light of manualized treatment. A manualized approach to treatment emphasizes treatment technique over treatment approach, and treatment content over treatment process, and hence approaches treatment as technical, although we have seen recent changes. For instance, Marshall (2006) writes that manualized treatment in work with adult sexual offenders doesn t allow for necessary flexibility in clinical style or the development of the therapeutic alliance. He notes that rigid adherence to a manual reduces, if not eliminates, clinical flexibility and restricts the expression of therapist features that he writes have repeatedly been shown to be central to treatment in both general clinical treatment and sexual offender specific treatment literature. Recognizing the strengths and limitations of manualized treatment, and highlighting the role of the clinician, Addis and Cardemil (2005) emphasize that the function of a treatment manual is not to replace the sensitive, creative, and flexible clinician but to assist in the dissemination and implementation of evidencebased treatment (p.135). Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 12

15 Our Changing Treatment Approach Not only moving away from our pursuit or adherence to manualized treatment, we also realize the need to change our approach to treatment. For example, in work with adult sexual offenders Beech and Hamilton-Giachritsis (2005) note a change in treatment technique from a direct and confrontational style, which they write is likely to lead to increased resistance rather than change, to the development of a supportive and emotionally responsive treatment relationship. In work with youthful sexual offenders, the same is true. Longo and Prescott (2006) write that the use of hostile, confrontational, and harsh treatment styles are ineffective with sexually abusive youth, and they instead stress the value of a warm, empathic, and rewarding approach in working with offenders. These relatively new ideas in sexual offender treatment that we need to build therapeutic alliances with our clients, help instill hope in them, and help them grow, rather than simply confront, challenge, and judge them are welcome, and bring the treatment of juvenile and adult sexual offenders closer to therapeutic principles and processes already found in mainstream psychotherapy. Our Changing Treatment Approach In our work as clinicians, we recognize the goal of attachment-informed treatment as the rehabilitation of the emotional and cognitive schema, or the current internal working model. Further, as we start to apply an attachment-informed ideas about treatment, whether in forensic or generic mental health treatment, we recognize that attachment work is no longer about the course of development but instead about the treatment relationships and bonds we form with our clients. Consequently, what we learn from attachment theory influences us in three broad interacting categories: 1. The way we think about and understand our clients, 2. Our ability to think about and plan our treatment interventions, and 3. The way that we interact with and relate to the people we are seeking to help. In application at the clinical level attachment theory is not only about the goals of social competence and connectedness that become the targets of treatment, but also and especially the relationships we form with our clients in creating the environments in which treatment occurs. The Attachment-Informed Therapist As noted, an attachment-informed approach informs, rather than defines, clinical thinking, providing a way for clinicians to think about early patterns of emotional regulation and behavior, helping them to better understand the developmental experience and behaviors of their clients. Attending to the manner in which attachment themes and organization are consciously and unconsciously expressed changes how therapists observe their clients and make sense of their cases, recognizing that the ability of the client to work with his or her therapist is profoundly shaped by the client's level of attachment security. A central task for the therapist is to become a source of security for the client, or a secure base (Bowlby, 1988), demanding "great sensitivity and empathy as the therapist adjusts to or feels his way into the patient's... attachment needs" (Brisch, 1999). Therapeutic empathy is central to the therapeutic relationship, and essential to the facilitative treatment environment through which individuals are able to recognize and modify their attitudes, behaviors, and self-concepts (Rogers, 1980). Empirically Based Principles of Therapeutic Change These ideas, and the idea that there are common factors found in all forms of effective treatment, are supported by the recent conclusions of the American Psychological Association s Task Force on Empirically Based Principles of Therapeutic Change (Castonguay & Beutler, 2006). Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 13

16 Empirically Based Principles of Therapeutic Change Out of 61 principles of therapeutic change, the Task Force reported the importance of client investment and participation in treatment, noting that effective treatments do not induce resistance in the client and that treatment outcome is enhanced if the client is willing to engage in the treatment process. With respect to the clinician, treatment effectiveness is likely to be enhanced if the therapist demonstrates open-mindedness and flexibility, is patient and able to tolerate any negative feelings he or she may experience about the client, and is comfortable with an emotionally connected treatment relationship. Further, treatment is likely to be beneficial if the therapist is able to facilitate a high degree of collaboration with the client, and if a therapeutic alliance is established and maintained in which clinicians both experience empathy for their clients and are experienced by their clients as authentic in the relationship. General Principles of Effective Treatment Client expectations are likely to play a role in treatment outcome. The clinician is likely to be more effective if patient with the client and the treatment process. Clinicians should relate to their clients in an empathic manner; an attitude of caring, warmth, and acceptance is helpful in facilitating therapeutic change; and therapists are likely to facilitate change when congruent and authentic. Therapists are likely to resolve alliance ruptures when addressing these in an empathic and flexible manner. Positive change is likely if the clinician provides structured treatment and remains focused on the application of interventions. The client s motivation for treatment is enhanced when the clinician conveys an understanding of how difficult it is for the client to change. Therapy is likely to be beneficial if the clinician helps facilitate change in client cognitions. The client is likely to benefit from therapy if the clinician helps the client modify maladaptive emotions and behavior. Facilitating client self-exploration can be helpful. Therapeutic change is likely if clinicians help clients accept, tolerate, and, at times, fully express their emotions. Interventions aimed at controlling emotions can be helpful. The Facilitative Treatment Relationship and the Treatment Alliance Norcross (2000) and Blanchard (1998) have described the therapist as a central agent of change. Bachelor and Horvath (1999) have written that the important therapeutic relationship is formed early in therapy, established through the climate of trust and safety fostered by the clinician through responsiveness, listening, and the communication of understanding, regard, and respect. Here, contrary to ideas that sexual offenders are bullied, coerced, or confronted into getting better, the therapeutic alliance provides an environment in which the sexual offender is able to willingly enter and engage in treatment. All of this speaks to the need for clinicians to engage clients in the treatment process and build a working relationship so that the client is an active participant in, and not simply the object of, the treatment process. Here, the client feels valued by and experiences empathy and warmth from the clinician, engages in a working alliance with the clinician, and experiences a genuine relationship with a genuine person, rather than sterile treatment with a treatment technician. This, then, is the heart of the therapeutic relationship, as true for work with juvenile sexual offenders as any other population. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 14

17 The Therapeutic Relationship Margaret Parish and Morris Eagle (2003) say that therapeutic relationship has many qualities of an attachment relationship. Patients: Admire and seek proximity to their therapists, Find their therapists emotionally available, Evoke mental representations of their therapists in the therapist's absence, and Experience their therapists as a secure base helping them to feel confident outside of therapy. They write that patients form strong emotional connections with their therapists and regard them as unique and irreplaceable. Fari Amini and colleagues write that therapy works because it is an attachment relationship "capable of regulating neurophysiology and altering underlying neural structure" (1996, p.232). The Nature of the Attachment-Informed Therapeutic Relationship We can identify 14 aspects of the attached therapeutic relationship, specifically from the perspective of the therapist s role in the relationship. 1. The therapist is experienced by the client as a dependable, consistent, and responsive emotional support. 2. The therapist facilitates a therapeutic relationship in which the client can develop security in the therapeutic relationship, form a bond with the therapist, and freely engage in self expression. 3. The therapist encourages both self-dependency and help-seeking in the client. 4. The therapist provides a secure base through which the client can feel recognized and connected, and from which the client may engage in exploration, recognizing, expressing, and working through problems. 5. The therapist uses attachment-related interactions in the therapeutic relationship as a means to understand the client and the client's attachment patterns and strategies. 6. The therapist becomes attuned to the client's emotional and attachment-related states, aware of the need for emotional connection. 7. The therapist helps the client to recognize and explore attachment relationships and strategies for maintaining connections. 8. The therapist helps the client recognize that current relationships, experiences, ideas, and attitudes are related to and the result of prior experiences and on-going attachment relationships. 9. The therapist challenges and stretches the client, remaining in the proximal learning zone, but creating opportunities for new learning. 10. The therapist creates and recognizes boundaries, and maintains an appropriate level of closeness fitting the needs and capacities, and the particular attachment style and needs, of each individual client. 11. The therapist remains aware of counter-transference issues, using these to better understand the client and the therapeutic alliance, guide treatment interventions, and maintain treatment boundaries. 12. The therapist maintains freedom of movement in the relationship, maintaining permeable boundaries, but able to move in and out of engagement with the client as needed. 13. The therapist helps the client develop the capacity to experience/tolerate difficulty, uncertainty, and doubt. 14. The therapist sensitively dissolves the therapeutic bond when appropriate, so that it will serve as a model for handling separations in life. Goals of Attachment-Informed Treatment In an attachment-informed approach to treatment, we recognize social relationships as the outcome of transactions and interactions between the internal mentalized world and the external physical world. In our work with clinical populations, the application of attachment theory is thus directed towards a psychology of social, emotional, and cognitive deficits. Accordingly, the goal is the rehabilitation of the current internal working model, in which healthy and non-pathological behaviors and the development of critical social skills are recognized as possible only when the client feels secure. Understanding Juvenile Sexual Offenders Through the Lens of Attachment Theory: Page 15