An Etiological Approach to Sexual Offender Assessment: CAse Formulation Incorporating Risk Assessment (CAFIRA)

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1 A Etiological Approach to Sexual Offeder Assessmet: CAse Formulatio Icorporatig Risk Assessmet (CAFIRA) New Directios i Sex Offeder Practice Coferece 16th & 17th April 2018 Uiversity of Birmigham Professor Leam A. Craig Cosultat Foresic Cliical Psychologist Foresic Psychology Practice Ltd Uiversity of Birmigham & Birmigham City Uiversity leamcraig@foresicpsychology.co.uk 1

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3 CF History 3

4 A psychotherapy CF is a hypothesis about the causes, precipitats ad maitaiig iflueces of a perso s psychological, iterpersoal ad behavioural problems (Eells, 2007). 4

5 Approaches to CFs Commo across all approaches CFs should: state/seek to explai the problem behaviour; based o a rage ad quality of evidece provide a accout of developmetal history provide psychological explaatios of problem behaviour; hypothesise to facilitate chage; be clearly uderstood (jargo free) Problem Ofte cross theoretical No theoretical CF risk model 5

6 a workig hypothesis.. CF summarizes ad itegrates a broad rage of biopsychosocial causal factors.. based o persoal meaig costructed collaboratively with service users. uderpied by psychological theory used to explai the etiology ad guides the itervetio process commuicate a plausible story i a theoretically guided way to explai the presetig problems, the explaatio beig uderpied by psychological theory. 6

7 Cliical Settigs Efficacy Addressig axiety / depressio (Kazdi, 2007; Persos et al., 2006), repressive copig (DeNeve & Cooper, 1998) maagig psychotic symptoms (Freema, Betall & Garety, 2008). Foresic Settigs CFs are becomig icreasigly more relevat. Expert Witess reports (Germay proposals). UK OPD Pathway. Reduced the umber priso recalls; Reduced o-compliace; Reduce challegig behaviours i offeders with PD. (Clarke & Chau, 2015) 7

8 CFs ad Sexual Offedig Risk Assessmets Typical Foresic Frameworks: ARAIs (e.g., RM2000/S; STATIC-2002R), SPJ (e.g., RSVP; SVR-20) (see Craig & Retteberger, 2016/17) A gradual move towards idividualised CFs ad stregthbased approaches to treatmet ad risk maagemet (Loga, 2016; Thakker, 2016). 8

9 Most commo: Method of CFs Five P s -method (Maceil, Hasty, Cous & Berk, 2012): presetig problem, predisposig factors, precipitatig factors, perpetuatig factors, ad protective/positive factors. Already beig adapted to the field of sexual offeder assessmet (Thakker, 2017). 9

10 Presetig Problem Provides a summary or descriptio of the mai problem behaviours, or behaviours which are causig the patiet the most difficulties. The curret behaviour or the behaviour which is the reaso for assessmet, sexually iappropriate, deviat ad/or deliquet behaviour. 10

11 Joh Doe Presetig Problem: Case Study Male, aged 20 years. Idetermiate setece: Idex offece: rape of child <14 years. Strager victim. (he was 15yrs) Presetig Hx: IO Hx of sexual pre-occupatio. Cliical Cocer Sexual arousal to fear respose i others ad extreme physical pai to self. [Extreme] Self-cuttig, masturbatory reiforced 11

12 Predisposig Factors Historical evets that might be liked Developmetal iflueces, Geetic vulerabilities, Experieces ad relatioships with parets (attachmet), Psychiatric issues ad livig situatios. The origis ad developmet of the problem behaviour. Oset/developmet of deviat fatasy/appetites/iterests Drawig o relevat theories: Psychosocial developmet across the lifespa (Marshall et al., 2006) Attachmet Theory (Aisworth, 1973; Bowlby, 1969), Social Learig Theory (Badura, 1977) Theories of persoality developmet ad socialisatio. The impact o trauma (Glasser et al, 2001) Sexual offeder specific theories (The Big 4 Theories). 12

13 Predisposig Factors RISK: psychological problems (stable dyamic risk factors), a idividual s history (static risk factors, crimiological iformatio about previous deliquecy ad developmetal problems), ad curret life circumstaces (acute or cotextual risk factors). Beech ad Ward (2004) aetiological model of risk: chai of evets from a distal developmetal factors sectio, vulerability factors (historical markers of risk ad stable dyamic psychological measures of risk at the time assessmet took place), a triggerig factors or cotextual evets sectio, ad acute risk factors sectio. 13

14 Aetiological Model of Risk (Beech & Ward, 2004) Distal factors Vulerability (Traits) factors State factors (state) Developmetal factors Abuse Rejectio Attachmet problems Historical markers Static factors, e.g., Persistece ad rage of offedig Psychosocial problems (e.g., ever married) Crimial/ Atisocial history Psychological dispositios Stable dyamic Sexual self regulatio Offese supportive cogitios Level of iterpersoal fuctioig Geeral selfregulatio problems Triggerig evets/ cotextual risk factors e.g., Victim access No-cooperatio with supervisio Social dislocatio Substace abuse Relatioship coflict Ati-social peers Acute dyamic Physiological Arousal Deviat thoughts ad fatasies Need for itimacy +/ ive Affective states L E V E L O F R I S K Time Course 14

15 ARAIs: Predisposig Factors RM2000/S (Thorto et al., 2003). SORAG (Quisey et al., 2006). The STATIC family (Haso et al) (see: Craig & Retteberger, 2016; Retteberger & Craig, 2017). Static risk factors Represetatios of psychological vulerabilities i the here ad ow from the idividual s past. Actuarial proxies (Beech & Ward, 2004). Features of these aetiological cosideratios which are represeted by differet theoretical ad coceptual approaches ca easily be icorporated ito a mixed risk assessmet ad CF model. Itegratig theory of adversity, theory of risk, theories offedig behaviour 15

16 CAse Formulatio Icorporatig Risk Assessmet (CAFIRA)

17 Marshall &Barbaree s (1990) Itegrated Theory Early Developmetal Experiece 1) Physical, emotioal ad/or sexual abuse 2) Witessig domestic violece/sexual assault Skills Deficits 1) Lack of social skills 2) Maladaptive workig model of relatioships (e.g. expect ot to be loved, expect fear ad aggressio, distrust) 3) A difficulty distiguishig betwee sexual ad violet impulses Adolescece/Puberty A key period i terms of developig sexual ad social idetity- due to the aforemetioed skills deficits, idividuals experiece difficulty i their iterpersoal relatioships- rejectio, ager, hostility. Thus, they develop maladaptive meas of meetig their ewly acquired sexual eeds, ofte fusig sexual ad aggressive scripts.

18 Predisposig Factors: Case Study Early developmet: Uevetful ifacy. Parets separated at 5 years (difficult separatio). Dizygotic twi brother, illess at 8 years. Extreme ager / violece towards brother ad mother Ejoyed fear respose Behaviours beyod paretal cotrol Not emotioally close (Dismissive Attachmet Style) to parets. Behaviours: Self-cuttig at 10 years. Risk behaviours (caabis/kife to school) Fightig i school (expelled) Socially awkward aroud peers Aimal cruelty (evisceratig cats/dislocatig limbs = arousig) Obsessed with Hallowee / Chucky Destructive behaviours at 13/14 years (fire, crim dmg). Behavioural triad 18

19 Predisposig Factors: Case Study Sexual Developmet always lookig for sex / very high sex drive (15 sexual parters). Blackmail of a umber of teeage female victims olie. Later, sex secodary to cotrol (arousig) 13/14 years: sexual arousal paired with self-cuttig geital cuttig group : arousal to pai ad blood. Cuttig ad arousal paired: (10 out of 10). High frequecy masturbatory behaviour to violet fatasies. IO: met victim olie. First time they met, watched Hallowee followed by forced sex. Sc2 MHA Summary Hypothesis Disruptio to attachmet / perceptios of rejectio. Violet/Agg behaviour outlet to maage emotios (reiforced) High sex drive / later cotrol (reiforced). Cuttig as a outlet becomes paired with arousal/fatasy (reiforced). SAVRY/ERASOR/RSVP etc 19

20 Perpetuatig Factors Mechaisms which keep a problem goig or uiteded cosequeces of a attempt to cope with the problem Crimiogeic Factors (Haso et al. 2009). Psychologically meaigful risk factors Deviat sexual arousal Itimacy (dysfuctioal attachmets) Socio-affective deficits (e.g., low self-esteem, fear of autoomy/rejectio), Poor self-maagemet (e.g., poor impulse cotrol, poor problem solvig), Offece supportive attitudes (e.g., sexual etitlemet attitudes, viewig childre as sexual agets) Implicit theories (Ward & Keea, 1999). Negative cogitive beliefs 20

21 Perpetuatig Factors (CAFIRA) The cocept of dyamic risk factors operatioalized as psychologically meaigful risk factors is today the psychometrically best way to capture perpetuatig factors for sexual offeder risk assessmet. Dyamic Risk Assessmet Frameworks: SARNR (Thorto, 2002; Webster et al) VRS-SO (Olver et al 2007) SVR20 (Boer et al, 1997) RSVP (Hart et al, 2003) 21

22 Stable Dyamic Factors ARAIs SPJ Dyamic Frameworks Sexual Iterests (obsessio / preoccupatio) STATIC- 99/2002 No-cotact sexual offese Urelated Victim Strager victim Prior sex offese Setecig occasios Male victim SORAG Deviat sexual preferece Prior sexual covictios Risk Matrix 2000/S Sexual appearaces Sexual offeses agaist a male No-cotact sexual offeses Strager victim SVR-20 (Boer et al. 2007) Deviat sexual preferece High frequecy sex offeses Multiple sexual offeses Escalatio of sexual offeses STABLE-2007 (Haso et al. 2007) Sexual preoccupatio/ sex drive Sex as a copig strategy Deviat sexual iterests SRA/SARN (Thorto, 2002; Webster et al, 2006) Sexual preoccupatio (obsessio) Sexual preferece for childre Sexualized violece Other offese related sexual iterests (fetish) Attitudes Supportive of Sexual Offese Pro-offedig attitudes (extreme miimizatio ad deial) Sexual etitlemet Pro-rape attitudes Child molester attitudes Adversarial sexual attitudes Sexual etitlemet Child abuse supportive beliefs Belief wome are deceitful Relatioships (Itimacy Deficits) No relatioships Never married Sigle (ever bee married) Relatioship problems Employmet problems Lack of lovers/itimate parters Emotioal idetificatio with childre Hostility toward wome Geeral social rejectio/loelies s Lack of cocer for others Persoal iadequacy Emotioal Cogruece with Childre Grievace Stace Emotioal loeliess (lack of itimate relatioships). Self-Regulatio Idex o-sex violece Prior o-sex violece Age ( ) Violet crimiality No-violet crimiality Psychopathy Failure of coditioal release Age (18-34) Crimial appearaces Violet o-sex offeses Geeral crimiality Psychopathy Impulsivity Impulsive acts Poor cogitive problem solvig skills Negative emotioality/ hostility Lifestyle Impulsiveess Impulsive, ustable lifestyle Poor problem solvig Poor emotioal 22

23 Perpetuatig Factors The Dyamic Predictors Project (DPP: Haso & Harris 2000/2010) N=208 kow to have reoffeded N=201 who had ot reoffeded Differetiated betwee two types of dyamic risk factors: Relatively stable edurig traits (e.g., offece supportive attitudes, cogitive distortios, or selfregulatio deficits) ad, Temporal / rapidly chageable acute risk factors foud i the eviromet ad situatioal cotext. 23

24 The Stable items divided ito six subsectios: 1. Social iflueces (1-item). Perpetuatig Factors 2. Itimacy deficits (5 items: dysfuctioal or hostile attitudes towards wome, social rejectio/loeliess, lack of cocer for others, lovers/itimate parters, emotioal cogruece with childre), 3. Sexual self-regulatio (3 items: deviat sexual iterests, the sex as copig, ad sex obsessio). 4. Attitudes supportive of assault (3 items: etitlemet, child molest attitudes, attitudes supportig sexual assault). 5. Geeral self-regulatio (3 items: egative emotioal states, poor problem, egative emotioality/hostility) 6. Co-operatio with supervisio (1 item). 24

25 Perpetuatig Factors 7 of the 16 items showed the most promise: egative social iflueces hostility toward wome rejectio/loeliess lack of cocer for others lack of cooperatio with supervisio impulsive acts poor cogitive problem-solvig 25

26 Perpetuatig Factors: Case Study Schizoid features (with some Atisocial, Narcissistic traits). Isolative, egocetricity, iflated sese of self-importace, A itese mistrust of others (schema). Lack of cocer for others. Poor cogitive problem solvig. Difficulty i uderstadig / readig emotioal cues. Socially isolated / poor peer relships. Closeess perceived as displays of weakess. Struggles to build relatioships where trust is viable: attedig Tx but ot fully egaged. (DPP: Haso & Harris 2000/2010) 26

27 Perpetuatig Factors: Case Study Algolagic Paraphilia: (ἄλγος, álgos, "pai", ad: λαγνεία, lageía, lust ) DSM-V: Sexual Masochism Disorder (life threateig cuts). Evisceratig/killig cats ad extreme self-ijurious behaviour to ivoke itese/substatial sexual excitemet. Automasochism / Autassassiophilia / Haematophilia / Zoosadism. reverse polarity reiforcemet. 27

28 Precipitatig Factors Triggers to the problem behaviour may be exteral (time or place) or iteral (thoughts ad feeligs). Beech & Ward (2004): stable (psychological vulerabilities) dyamic ad acute (trigger) dyamic risk factors better reframed as: trait risk factors (i.e., edurig persoality problems), ad state risk factors (i.e., the temporary, usually extreme expressio of the more edurig stable dyamic risk factors). 28

29 Precipitatig Factors DPP: There is oly oe empirically soud ARAI used to assess acute risk factors for sexual offeders: Acute 2007 (8 items): Victim access Emotioal collapse Collapse of social supports Hostility Substace abuse Sexual pre-occupatio Rejectio of supervisio Uique risk factor 29

30 Precipitatig Factors: Case Study Behavioural Cycle: thought processes ad arousal patters. Trait Vulerabilities Arousal patters ad cogitios Behaviours desiged elicit respose (for the self ad from others) State Vulerabilities Stressors withi the eviromet Feelig a lack cotrol / destiy Build up of frustratio (eed for release) 30

31 Protective/Stregth-Based Factors Promotes more comprehesive, balaced, ad optimistic views of cliets ad their situatios tha deficit-based models, Positive emphasis is also oe of several factors associated with treatmet effectiveess. GLM: Ward ad colleagues: 10 primary goods - problems i fuctioig result whe these primary goods are pursued i iappropriate ways. 31

32 Protective/Stregth-Based Factors Empirical support for protective factors (ad the GLM) is still i its early days, evidece of desistace, based o GLM priciples, ca be observed i other fields of psychology ad psychiatry. Farmer, Beech ad Ward (2012) two groups of child molesters; those deemed to be desistig, ad those deemed to beig still potetially active offeders. desistig group optimistic for the future, ehaced sese of persoal agecy iteralized locus of cotrol, idetified treatmet as beig a turig poit i their lives. 32

33 Protective/Stregth-Based Factors Refocus of itervetio (Mews et al., 2017). Kaize: based upo the RNR priciples (desiged for high risk, high eed, high priority offeders). Horizo: based upo crimiogeic eeds, poor problem solvig, poor self-regulatio ad relatioship difficulties (desiged for medium risk offeders). both programs are based o stregth-based approaches, positively orietated ad cetred o the ideas of the GML. 33

34 Protective Factors: Case Study A umber of cliical cotradictios: Appears ope to therapeutic egagemet Elemets of plasticity about his persoality He is egagig with 1:1, issues of trust impedig progress. Tx iteractio uderpied by attachmet style: overcome mistrust Restructure egative schema. Admits becomig embarrassed whe sexually aroused while receivig medical treatmet for self-cuts. Issues Arrested social/emotioal developmet Etreched patter of sexual arousal ad behaviours are ulikely to be maaged by traditioal cogitive programmes aloe SSRI / Ati-libidial meds / Behavioural strategies 34

Psychological explaatio It is hypothesised, displaced ager from perceived childhood rejectio, impactig o attachmet ad trust, coupled with selfijurious behaviour became rewardig ad paired with sexual

35 Psychological explaatio It is hypothesised, displaced ager from perceived childhood rejectio, impactig o attachmet ad trust, coupled with selfijurious behaviour became rewardig ad paired with sexual arousal, later reiforced. Cotrol aspects of behaviour desiged to protect the self from further hurt (rejectio). Persoality traits ad difficulties with itimacy ad emotioal recogitio impeded usual empathic resposes to viewig fear ad hurt i others, later became rewardig ad reiforced. Recommedatios/ Actios: Itervetio based o uderstadig attachmet style ad fosterig trust. Etreched patter of sexual arousal ad behaviours are ulikely to be maaged by traditioal cogitive programmes aloe: SSRI / Ati-libidial meds. Future risk will be reduced if he effectively applies problem-solvig skills to maage arousal ad stressors, develop trustig relatioships. 35

36 Coclusios Formulatios ca improve uderstadig of idividual problems ad risk behaviour Risk formulatios may provide a crucial lik betwee assessmet ad maagemet. Itegratig risk formulatios ito the CF provides a coceptually robust lik. The CAFIRA-Model, Seeks to itegrate: theories of developmetal adversity, theories offedig behaviour, ad theory of risk assessmet withi the methodology of CF RF explicit theoretically uderpied supported by empirical literature 36

37 Professor Leam A. Craig Cosultat Foresic Cliical Psychologist Foresic Psychology Practice Ltd Uiversity of Birmigham & Birmigham City Uiversity Craig, L. A., & Retteberger, M. (i press). A Etiological Approach to Sexual Offeder Assessmet: CAse Formulatio Icorporatig Risk Assessmet (CAFIRA). Curret Psychiatry Reports: Special Issue 37

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